The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:

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Question 1 of 9

The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:

Correct Answer: D

Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.

Question 2 of 9

The papule on the nose of a 52-year-old woman has rounded, pearly borders and a central red ulcer. She tells the nurse that it has been present for several months and is slowly growing larger. Which of the following conditions does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Basal cell carcinoma. The clinical presentation of a papule with rounded, pearly borders, central red ulcer, slow growth, and location on the nose is highly indicative of basal cell carcinoma. Basal cell carcinoma commonly presents with these characteristics and is the most common type of skin cancer. It is locally invasive but rarely metastasizes. A: Acne is a common skin condition characterized by comedones, papules, and pustules, not typically presenting with the described features. C: Malignant melanoma usually presents as an asymmetric, irregularly bordered, multicolored lesion with rapid growth and potential for metastasis. D: Squamous cell carcinoma typically presents as a scaly, crusted lesion with potential for metastasis, not showing the described features.

Question 3 of 9

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 4 of 9

Which of the following assessment findings is most consistent with clubbing of the fingernails?

Correct Answer: D

Rationale: Clubbing of the fingernails is characterized by an increased angle between the nail base and the nail plate (usually 180 degrees or greater) and a spongy texture at the nail base. This is due to underlying tissue changes associated with conditions like lung disease. Choice D is correct as it accurately describes the characteristic findings of clubbing. Choices A, B, and C do not align with clubbing features. Choice A describes tenderness and firmness, not sponginess and increased angle. Choice B mentions a convex profile and ridges, which are not specific to clubbing. Choice C includes an angle of 150 degrees, which is less than the typical angle seen in clubbing.

Question 5 of 9

The nurse is performing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, grey, and swollen. What would be the most appropriate question to ask the patient?

Correct Answer: A

Rationale: The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms. B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction. C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction. D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.

Question 6 of 9

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

Correct Answer: C

Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).

Question 7 of 9

A mother brings her child in to the clinic for scalp and hair examination. She says that the child has developed irregularly shaped patches on her head with broken-off, stublike hair, and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is:

Correct Answer: D

Rationale: The correct answer is D: trichotillomania, which may be caused by her child habitually twirling her hair in an absent-minded way. Trichotillomania is a psychological disorder where individuals have an irresistible urge to pull out their hair. In this case, the broken-off, stublike hair and irregularly shaped patches on the child's head are indicative of hair pulling rather than a medical condition like folliculitis (choice A), traumatic alopecia (choice B), or tinea capitis (choice C). The child's hair being kept very short does not align with the characteristic of these conditions, making trichotillomania the most likely explanation.

Question 8 of 9

The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?

Correct Answer: A

Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.

Question 9 of 9

During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. What condition does the nurse suspect?

Correct Answer: C

Rationale: The correct answer is C: Temporal arteritis. Temporal arteritis is characterized by inflammation of the temporal arteries, leading to symptoms such as tenderness, hardness, and tortuosity. The left temporal artery being more affected than the right is a common presentation. Crepitation (choice A) refers to a crackling sound or sensation, typically associated with bone or joint abnormalities, not arterial inflammation. Mastoiditis (choice B) is an infection of the mastoid bone behind the ear, not related to temporal arteries. Bell's palsy (choice D) is a condition affecting facial nerves, not arteries.

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