The nurse is conducting a hearing assessment using the Romberg test. The nurse is assessing for:

Correct Answer: D

Rationale: The Romberg test assesses the maintenance of standing balance by having the patient stand with feet together, arms at the sides, and eyes closed. If the patient sways or loses balance, it may indicate proprioceptive deficits. Conductive hearing loss (A) is related to sound transmission issues in the outer or middle ear, not balance. Lateralization of hearing (B) relates to distinguishing sound direction. Sensorineural loss (C) involves inner ear or auditory nerve damage, not balance. Therefore, the correct answer is D as the Romberg test specifically evaluates standing balance.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates cultural sensitivity and respect for the patient's comfort. Placing the nurse's thumbs on either side of the trachea and tilting the patient's head forward is a non-threatening and non-invasive approach to examining the thyroid. This position allows the nurse to assess the thyroid gland without causing discomfort or intimidation to the patient. Choice A is incorrect because having the nurse's hands placed firmly around the neck from behind may be perceived as invasive and threatening to the patient. Choice B is incorrect because having the nurse's thumbs on the patient's neck with eyes averted toward the ceiling may come across as awkward and unprofessional. Choice D is incorrect because tilting the patient's head backward can cause discomfort and may not be culturally sensitive as it can be perceived as invasive.

Correct Answer: D

Rationale: The correct answer is D because cranial nerve X, also known as the vagus nerve, controls the movement of the soft palate and uvula. Asking the patient to say "ahhh" assesses the function of CN X as the soft palate and uvula should elevate symmetrically. A: Observing the patient's ability to articulate specific words does not specifically test CN X function. B: Assessing movement of the hard palate and uvula with the gag reflex primarily tests CN IX (glossopharyngeal nerve). C: Having the patient stick out the tongue and observing for tremors or pulling to one side primarily tests CN XII (hypoglossal nerve).

Correct Answer: A

Rationale: The correct answer is A: auricle. The auricle is the visible, outer portion of the ear made up of movable cartilage and skin. It serves to collect sound waves and direct them into the ear canal. The other choices are incorrect because the concha (B) is the concave cavity leading to the ear canal, the outer meatus (C) is the ear canal itself, and the mastoid process (D) is a bony protrusion behind the ear that has no role in sound collection.

Correct Answer: D

Rationale: The correct answer is D, an ulceration with rolled edges on the side of the tongue, as it could indicate a possible malignancy such as oral cancer. The presence of rolled edges is concerning for malignancy due to the irregularity in shape and potential for rapid growth. This finding should be promptly investigated to rule out cancer. A: A painful vesicle inside the cheek for 2 days is likely a benign condition such as a canker sore. B: The presence of moist, nontender Stenson's ducts is a normal finding in the mouth. C: Stippled gingival margins that adhere snugly to the teeth could indicate a healthy gum tissue attachment. In summary, the other choices are less concerning as they are either benign or normal variations, while the presence of an ulceration with rolled edges raises significant suspicion for malignancy.

Correct Answer: B

Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.

Correct Answer: D

Rationale: The correct answer is D: increased intracranial pressure. Papilledema is swelling of the optic disc due to increased pressure in the brain. It is a sign of serious conditions like brain tumors, head trauma, or hydrocephalus. The other choices are incorrect because retinal detachment presents with visual disturbances and floaters (A), diabetic retinopathy with retinal damage due to diabetes (B), and acute-angle glaucoma with sudden eye pain and blurred vision (C). Papilledema specifically indicates increased intracranial pressure, making choice D the correct answer.

Correct Answer: D

Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.

Correct Answer: B

Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice D) is not relevant to testing the function of CN XI.