nclex physical and health assessment questions -Nurselytic

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nclex physical and health assessment questions Questions

Question 1 of 5

While performing a voice test to assess hearing in a patient, which of the following would the nurse do?

Correct Answer: B

Rationale:
Correct Answer: B


Rationale:
1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity.
2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately.
3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment.

Summary:
A: Shielding the lips while speaking would hinder the patient's ability to hear clearly.
C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test.
D: Standing at a specific distance does not ensure accurate assessment of hearing ability.

Question 2 of 5

A patient presents with excruciating pain on one side of his head, especially around his eye, forehead, and cheek, that occurs once or twice each day and lasts about 30 minutes to 2 hours. The nurse suspects:

Correct Answer: B

Rationale: The correct answer is B: cluster headaches. Cluster headaches are characterized by excruciating pain on one side of the head, often around the eye, forehead, and cheek. They occur once or twice each day and last for a relatively short duration of 30 minutes to 2 hours. This pattern of symptoms aligns with the typical presentation of cluster headaches.

Incorrect

Choices:
A: Hypertension is unlikely to present with such specific unilateral head pain patterns and timing.
C: Tension headaches typically present with more diffuse, mild to moderate pain and are not typically associated with eye, forehead, or cheek pain.
D: Migraine headaches usually last longer than 2 hours and are commonly associated with other symptoms such as nausea, vomiting, and sensitivity to light and sound.

Question 3 of 5

Which of the following assessment findings would the nurse be most concerned about?

Correct Answer: D

Rationale: The correct answer is D, an ulceration with rolled edges on the side of the tongue, as it could indicate a possible malignancy such as oral cancer. The presence of rolled edges is concerning for malignancy due to the irregularity in shape and potential for rapid growth. This finding should be promptly investigated to rule out cancer.

A: A painful vesicle inside the cheek for 2 days is likely a benign condition such as a canker sore.
B: The presence of moist, nontender Stenson's ducts is a normal finding in the mouth.
C: Stippled gingival margins that adhere snugly to the teeth could indicate a healthy gum tissue attachment.

In summary, the other choices are less concerning as they are either benign or normal variations, while the presence of an ulceration with rolled edges raises significant suspicion for malignancy.

Question 4 of 5

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o'clock position in each eye. The nurse would:

Correct Answer: C

Rationale: The correct answer is C: document this as an asymmetrical light reflex. This finding indicates an asymmetry in the corneal light reflex, suggesting a possible deviation in eye alignment or muscle weakness. It is essential to document this observation for further evaluation and monitoring.
Choice A is incorrect as asymmetry in the light reflex is not a normal finding. Referring for further evaluation (
Choice
B) would be appropriate if the asymmetry persists or is associated with other concerning symptoms. Performing the confrontation test (
Choice
D) is not necessary for this specific assessment and finding.

Question 5 of 5

The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?

Correct Answer: A

Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present.

Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection.
Therefore, the absence of any sensation is the expected response when the sinuses are normal.

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