A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?

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Question 1 of 9

A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?

Correct Answer: D

Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.

Question 2 of 9

The nurse suspects that a patient has hyperthyroidism, and laboratory data also indicate that the patient's T and T hormone levels are elevated. Which of the following would the nurse most likely find on 4 3 examination?

Correct Answer: A

Rationale: Step-by-step rationale for why choice A (Tachycardia) is correct: 1. Hyperthyroidism leads to increased production of thyroid hormones. 2. Thyroid hormones can increase metabolic rate and heart rate. 3. Tachycardia is a common symptom of hyperthyroidism due to increased metabolic demand. 4. Therefore, the nurse would most likely find tachycardia on examination in a patient with hyperthyroidism. Summary of why other choices are incorrect: B: Constipation - Constipation is more commonly associated with hypothyroidism, not hyperthyroidism. C: Rapid dyspnea - Dyspnea (shortness of breath) is not a typical symptom of hyperthyroidism. D: Atrophied, nodular thyroid - Hyperthyroidism often presents with an enlarged, not atrophied, thyroid gland due to overactivity. Nodules may be present in conditions like thyroid cancer, but not specific to hyper

Question 3 of 9

A woman has noticed that her son, who has a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:

Correct Answer: B

Rationale: The correct answer is B: impetigo. The characteristics of moist, thin-roofed vesicles with a thin erythematous base are classic features of impetigo, a bacterial skin infection commonly seen in children. Impetigo is highly contagious and commonly affects the face and buttocks. The presence of blisters and scabs further supports the diagnosis of impetigo. Explanation of other choices: A: Eczema typically presents as dry, itchy patches of skin with redness and scaling. It does not usually manifest as vesicles or blisters. C: Herpes zoster, also known as shingles, presents as a painful rash with grouped vesicles on one side of the body along a nerve pathway. It is uncommon in children and usually affects older individuals. D: Diaper dermatitis is a common rash in infants due to prolonged skin exposure to urine and feces. It typically presents as redness, irritation, and possibly skin breakdown in the diaper

Question 4 of 9

The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?

Correct Answer: A

Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.

Question 5 of 9

During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small, compared with an enlarged cranium. On further examination, the nurse also notes dilated scalp veins and downcast, or"setting sun," eyes. What condition does the nurse suspect?

Correct Answer: C

Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.

Question 6 of 9

A 31-year-old patient tells the nurse that he is experiencing a progressive loss of hearing. He says that it does seem to help when people speak more loudly or if he turns up the volume. The most likely cause of his hearing loss is:

Correct Answer: A

Rationale: The correct answer is A: otosclerosis. Otosclerosis is a condition where abnormal bone growth in the middle ear causes hearing loss. In this case, the patient's symptoms of progressive hearing loss improving with louder sounds suggest conductive hearing loss, which is commonly seen in otosclerosis. Other choices are incorrect because presbycusis is age-related hearing loss, trauma to the bones would typically result in sudden hearing loss, and frequent ear infections are more likely to cause temporary hearing loss rather than progressive loss.

Question 7 of 9

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. Ptosis is:

Correct Answer: C

Rationale: The correct answer is C: drooping of the upper eyelid. Ptosis refers to the drooping of the upper eyelid, which may occur due to weakened eyelid muscles or nerve damage. In this case, the nurse suspects ptosis in the 60-year-old man, which is likely due to age-related muscle weakness. Choice A, a cloudy cornea, is incorrect as it refers to a different eye condition. Choice B, an unequal red reflex, is incorrect as it is related to abnormalities in the retina. Choice D, protruding and bulging eyes, is incorrect as it indicates exophthalmos, a condition typically seen in thyroid eye disease.

Question 8 of 9

In a patient with anisocoria, the nurse would expect to observe:

Correct Answer: C

Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.

Question 9 of 9

The mother of a 2-year-old is concerned about tympanostomy tubes that are going to be inserted in her son's ears. Which of the following would the nurse include in the teaching plan?

Correct Answer: D

Rationale: Rationale for Correct Answer D: Tympanostomy tubes are inserted into the eardrum to help drain fluid from the middle ear, relieve pressure, and prevent infections. This is important in children who have recurrent ear infections or fluid buildup. By allowing drainage, the tubes help improve hearing and reduce the risk of complications. Summary of Incorrect Choices: A) Incorrect - Tympanostomy tubes are placed in the middle ear, not the inner ear. B) Incorrect - Tympanostomy tubes are used for conductive hearing loss, not sensorineural loss. C) Incorrect - Tympanostomy tubes are not permanently inserted and are usually removed after a period of time once they are no longer needed.

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