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. In an acute infection, such as streptococcal pharyngitis, the tonsils may exhibit yellowish exudates due to bacterial pus formation. This is consistent with the presence of inflammation and infection. Choices A, B, and C describe varying degrees of tonsillar enlargement and white debris, which could be present in different conditions but are not as specific to acute infection. Therefore, the presence of yellowish exudates on the tonsils is the key indicator of an acute bacterial infection like strep throat.

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: C

Rationale: The correct answer is C: CN VIII. The vestibulocochlear nerve (CN VIII) is responsible for conducting nerve impulses from the organ of Corti in the inner ear to the brain. This nerve specifically carries auditory information to the brainstem and auditory cortex for processing. Choice A (CN I) is incorrect as it is the olfactory nerve responsible for smell. Choice B (CN III) is incorrect as it is the oculomotor nerve responsible for eye movement. Choice D (CN XI) is incorrect as it is the accessory nerve responsible for neck and shoulder movements.

Correct Answer: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.

Correct Answer: D

Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment. Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child. Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.

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: B

Rationale: The correct answer is B, loss of lens elasticity. Presbyopia is the age-related loss of near vision due to the lens becoming less flexible, making it harder to focus on close objects. With aging, the lens loses its ability to change shape, affecting near vision. Other choices are incorrect because presbyopia is primarily related to changes in the lens, not the cornea (A), adaptation to darkness (C), or distance vision abilities (D).

Correct Answer: B

Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.