Questions 9

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Question 1 of 5

An 85-year-old female patient is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse provide?

Correct Answer: C

Rationale: The correct answer is C because as individuals age, there is a natural decrease in skin elasticity, subcutaneous fat, and moisture content in the skin. These factors contribute to the bones becoming more noticeable in the face. Choice A is incorrect because diets low in protein and high in carbohydrates do not directly cause enlargement of facial bones. Choice B is incorrect as the use of a specific moisturizer does not directly impact the visibility of facial bones. Choice D is incorrect because facial skin actually loses elasticity with age, leading to less taut skin and more prominent bones.

Question 2 of 5

During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.

Question 3 of 5

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 5

A patient has a normal pupillary light reflex. The nurse recognizes this to indicate that:

Correct Answer: D

Rationale: The correct answer is D because a normal pupillary light reflex involves the constriction of both pupils in response to bright light. This reflex is controlled by the autonomic nervous system, specifically the parasympathetic nervous system. When light is detected by the retina, signals are sent to the brain which then triggers the constriction of both pupils to reduce the amount of light entering the eye. Choices A, B, and C are incorrect because they do not accurately describe the pupillary light reflex. Vision convergence, light reflection, and focusing the image at the center of the pupil are not directly related to the pupillary light reflex.

Question 5 of 5

In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Red glow in pupils indicates a normal reflection off the inner retina known as the red reflex. 2. The red reflex helps to visualize the internal structures of the eye, including the retina. 3. This finding is expected during an ophthalmoscopic examination. 4. No abnormality is suggested by the presence of a red glow in the pupils. Summary of Other Choices: A: Incorrect. Red glow does not indicate an opacity in the lens or cornea. B: Incorrect. Checking the light source is unnecessary as red glow is a normal finding. D: Incorrect. Referral is not needed as red reflex is a normal part of an ophthalmoscopic exam.

Similar Questions

In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:
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