Correct Answer: A

Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.

Correct Answer: C

Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan.



Choices A, B, and D are incorrect:
A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause.
B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment.
D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.

Correct Answer: A

Rationale: The correct answer is A: Age-related hearing loss begins in the mid-40s. This is because presbycusis, or age-related hearing loss, typically starts around the mid-40s due to natural aging processes affecting the inner ear.
Choice B is incorrect as the progression of hearing loss can vary, being gradual for some individuals but not necessarily slow for everyone.
Choice C is incorrect as high-frequency tone loss, not low-frequency, is commonly associated with aging.
Choice D is incorrect as difficulty hearing consonants is more related to specific types of hearing loss, not solely age-related changes.

Correct Answer: B

Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice
A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice
C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice
D) is not relevant to testing the function of CN XI.

Correct Answer: C

Rationale: The correct answer is C: In an individual who is severely dehydrated. Decreased skin turgor is a clinical sign of dehydration, indicating loss of skin elasticity due to fluid loss. Severe dehydration leads to decreased skin turgor as the skin loses its ability to recoil when pinched. In cases of severe obesity (choice
A), skin turgor is usually normal or increased due to excess adipose tissue. During childhood growth spurts (choice
B), skin turgor is typically unaffected. Connective tissue disorders like scleroderma (choice
D) can lead to changes in skin texture and appearance, but not necessarily decreased skin turgor.