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Questions 46

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Question 1 of 5

During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do?

Correct Answer: D

Rationale: The correct answer is D because a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management.

A: Continuing the examination is not appropriate as the bruit should prompt further investigation.
B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue.
C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.

Question 2 of 5

The projections in the nasal cavity that increase the surface area are called the:

Correct Answer: C

Rationale: The correct answer is C: turbinates. Turbinates are bony projections in the nasal cavity that increase the surface area for the warming, humidifying, and filtering of inhaled air. Meatus (
A) refers to the passages in the nasal cavity, not the projections. Septum (
B) is the partition between the nostrils, not the projections. Kiesselbach's plexus (
D) is a collection of blood vessels in the nasal septum, not the projections that increase surface area.

Question 3 of 5

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. Which of the following would be an appropriate response by the nurse?

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections.


Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong.
Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections.
Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.

Question 4 of 5

While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?

Correct Answer: B

Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option
A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option
C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option
D) is not indicated unless there are specific symptoms or signs of infection.

Question 5 of 5

When a light is directed across the iris of the eye from the temporal side, the examiner is assessing for:

Correct Answer: C

Rationale: The correct answer is C: the presence of shadows, which may indicate glaucoma. When a light is directed across the iris from the temporal side, it helps in evaluating the presence of shadows in the anterior chamber angle, which can suggest a narrow or closed angle glaucoma. This technique is known as transillumination test and is important in detecting potential glaucoma cases.

A: Drainage from dacryocystitis is incorrect as it is typically assessed by pressing on the lacrimal sac area to observe for discharge.
B: Conjunctivitis over the iris is incorrect as conjunctivitis is an inflammation of the conjunctiva, not the iris.
D: A scattered light reflex indicative of cataracts is incorrect as cataracts cause clouding of the lens, not scattering of light across the iris.

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