The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?

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nclex practice questions 2023 health assessment Questions

Question 1 of 9

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?

Correct Answer: C

Rationale: The correct answer is C: Erythematous scaly patch with sharp margins in the sacral area. In patients with AIDS, this presentation is most likely indicative of a common opportunistic infection called tinea corporis. This fungal infection often presents as erythematous scaly patches with well-defined borders. The location in the sacral area is also common due to the warm and moist environment. Choice A, tinea capitis, is a fungal infection of the scalp and is not typically associated with AIDS. Choice B describes a presentation more indicative of a condition like seborrheic dermatitis rather than an AIDS-related skin manifestation. Choice D describes a presentation more typical of tinea corporis, which is not commonly seen in the axilla region in patients with AIDS.

Question 2 of 9

The salivary gland that is located in the cheek in front of the ear is the:

Correct Answer: A

Rationale: The correct answer is A: parotid gland. This gland is located in the cheek in front of the ear. It is the largest salivary gland in the human body. The parotid gland secretes saliva into the mouth through Stenson's duct. The other choices are incorrect because Stenson's gland does not exist, the sublingual gland is located under the tongue, and the submandibular gland is located under the mandible. Therefore, the parotid gland is the only gland that fits the description given in the question.

Question 3 of 9

A patient reports a severe throbbing headache in the frontotemporal area of his head that he experienced while studying for an examination, He says that the headache was somewhat relieved when he lay down. He tells the nurse that his mother also used to get these headaches. The nurse suspects that he may be suffering from:

Correct Answer: D

Rationale: The correct answer is D: migraine headaches. The patient's symptoms of severe throbbing headache in the frontotemporal area, triggered by stress (studying for an exam), partially relieved by lying down, and family history of similar headaches are indicative of migraines. Migraines commonly present with these characteristics, often exacerbated by stress and have a genetic component. A: Hypertension does not typically present with throbbing headaches in a specific area or relief with lying down. B: Cluster headaches are characterized by severe, unilateral headaches around the eye area, not frontotemporal. C: Tension headaches usually present as dull, constant pressure-type headaches, not throbbing, and do not have the familial pattern described by the patient.

Question 4 of 9

Which of the following statements regarding visual pathways and visual fields is true?

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.

Question 5 of 9

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?

Correct Answer: C

Rationale: The correct answer is C: Erythematous scaly patch with sharp margins in the sacral area. In patients with AIDS, this presentation is most likely indicative of a common opportunistic infection called tinea corporis. This fungal infection often presents as erythematous scaly patches with well-defined borders. The location in the sacral area is also common due to the warm and moist environment. Choice A, tinea capitis, is a fungal infection of the scalp and is not typically associated with AIDS. Choice B describes a presentation more indicative of a condition like seborrheic dermatitis rather than an AIDS-related skin manifestation. Choice D describes a presentation more typical of tinea corporis, which is not commonly seen in the axilla region in patients with AIDS.

Question 6 of 9

The nurse is aware that all of the areas in the body where lymph nodes are accessible for examination are the:

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.

Question 7 of 9

During a well-baby checkup, the mother expresses concern that her 2-month-old infant is not able to hold her head up when she is pulled to a sitting position. Which of the following responses by the nurse is appropriate?

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.

Question 8 of 9

The primary purpose of the ciliated mucous membrane in the nose is to:

Correct Answer: B

Rationale: The correct answer is B: filter out dust and bacteria. The ciliated mucous membrane in the nose traps dust and bacteria present in the inhaled air through the mucus layer and then moves them towards the throat to be swallowed or expelled. This helps in protecting the respiratory system from harmful particles. Choice A is incorrect as the warming of inhaled air is primarily done by the nasal passages and sinuses, not the ciliated mucous membrane. Choice C is incorrect because the filtering of coarse particles is also done by the nasal hairs and the mucous membrane working together, not just the ciliated mucous membrane alone. Choice D is incorrect as the movement of air through the nares is mainly controlled by the size of the nostrils and is not the primary function of the ciliated mucous membrane.

Question 9 of 9

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

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.

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