During the oral assessment of a 30-year-old patient of African descent, the nurse notes bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bluish lips indicate cyanosis, a sign of inadequate oxygen supply. 2. Dark line along gingival margin suggests lead poisoning. 3. The nurse should assess for other signs of inadequate oxygen supply to determine the severity and underlying cause. 4. This finding is not normal and requires further evaluation to prevent complications. Summary: A: Checking hemoglobin for anemia is not the immediate priority when cyanosis and lead poisoning are suspected. C: Assuming this is a normal finding can lead to overlooking a potentially serious condition. D: Carbon monoxide exposure could be a consideration, but assessing for overall oxygen supply is more crucial in this scenario.

Correct Answer: D

Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important as dryness in the mouth can be a side effect of certain medications used to manage hypertension and chronic lung disease. Dry mouth can lead to oral health issues and impact the patient's overall well-being. A: "Do you use a fluoride supplement?" is not directly relevant to the patient's medical history of hypertension and lung disease. B: "Have you had tonsillitis in the last year?" is not as crucial as dry mouth in relation to managing hypertension and lung disease. C: "At what age did you get your first tooth?" is not pertinent to the current medical conditions and management of hypertension and lung disease. In summary, the question about dryness in the mouth is the most relevant as it pertains to potential medication side effects and oral health implications for the patient with hypertension and chronic lung disease.

Correct Answer: C

Rationale: The correct answer is C because a bruit is a soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. This sound indicates turbulent blood flow, often due to a narrowed or blocked artery. Using the bell of the stethoscope allows for better detection of low-frequency sounds like bruits. A is incorrect because a low gurgling sound is not indicative of a bruit. B is incorrect because a loud, whooshing, blowing sound is not characteristic of a bruit. D is incorrect because a high-pitched tinkling sound is not typically associated with a bruit. In summary, the correct answer is C because it accurately describes the characteristics of a bruit, while the other choices do not align with the typical sound of a bruit.

Correct Answer: D

Rationale: The presence of black and white dots on the tympanic membrane and ear canal wall during an otoscopic examination suggests a yeast or fungal infection. This is because yeast or fungal infections commonly present as white or black dots in the ear canal. Malignancy would typically manifest as abnormal growths or masses, not dots. Viral infections usually do not present as specific dots on the tympanic membrane. Blood in the middle ear would appear as red or pinkish fluid behind the eardrum, not as black and white dots. Therefore, the correct answer is D: Yeast or fungal infection.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Head control typically develops around 4 months, so it is normal for a 2-month-old to lack this skill. 2. Reassuring the mother that her baby is within the normal developmental range is important for reducing parental anxiety. 3. Avoiding overly alarming responses helps maintain trust and open communication with the parent. Summary: - Choice B is incorrect as it does not address the mother's concern and may come across as dismissive. - Choice C is incorrect as it may unnecessarily worry the mother and lead to undue stress. - Choice D is incorrect as it introduces a serious and unlikely scenario without evidence at this stage of development.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bluish lips indicate cyanosis, a sign of inadequate oxygen supply. 2. Dark line along gingival margin suggests lead poisoning. 3. The nurse should assess for other signs of inadequate oxygen supply to determine the severity and underlying cause. 4. This finding is not normal and requires further evaluation to prevent complications. Summary: A: Checking hemoglobin for anemia is not the immediate priority when cyanosis and lead poisoning are suspected. C: Assuming this is a normal finding can lead to overlooking a potentially serious condition. D: Carbon monoxide exposure could be a consideration, but assessing for overall oxygen supply is more crucial in this scenario.

Correct Answer: B

Rationale: The correct answer is B because the image formed on the retina is indeed upside down and reversed from its actual appearance in the outside world due to the way light rays are refracted and focused by the cornea and lens. This phenomenon is known as the inverted retinal image. Choice A is incorrect as visual pathways cross at the optic chiasm, so the right side of the brain interprets vision for the left visual field from both eyes. Choice C is incorrect as light rays are refracted at the cornea and lens, not through the transparent media of the eye before striking the pupil. Choice D is incorrect as light impulses are conducted through the optic nerve to the occipital lobes, not the temporal lobes, where the primary visual cortex is located.

Correct Answer: B

Rationale: The correct answer is B because rubella can indeed damage the organ of Corti in the fetus, which is responsible for hearing. During the first trimester, when the hearing structures are forming, any damage to the organ of Corti can result in impaired hearing for the infant. Choice A is incorrect because rubella can impact the fetus, including the organs responsible for hearing. Choice C is incorrect because rubella can be harmful to the fetus at any stage of pregnancy, not just the second trimester. Choice D is incorrect because CN VIII (the vestibulocochlear nerve) is not directly affected by rubella, rather it is the organ of Corti that is damaged.

Correct Answer: C

Rationale: The correct answer is C because lymph nodes are accessible for examination in the head and neck, arms, breasts, and axillae. Lymph nodes are present in these areas where they can be easily palpated and assessed for any signs of inflammation or abnormalities. The other choices are incorrect because they do not include all the areas where lymph nodes are accessible for examination. Choice A does not include the axillae, which is a crucial area for examining lymph nodes in the arms. Choice B does not include the axillae and breasts. Choice D does not include the breasts, which are important areas for lymph node examination in cases of breast cancer or other breast-related conditions.