Questions 9

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nclex physical and health assessment questions Questions

Question 1 of 5

The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?

Correct Answer: D

Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles. Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.

Question 2 of 5

The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?

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.

Question 3 of 5

During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:

Correct Answer: D

Rationale: The correct answer is D: the bony labyrinth. The bony labyrinth is the portion of the inner ear that includes the vestibular system responsible for balance and spatial orientation. This system detects rotational movements and contributes to the sensation of vertigo or spinning. Choice A, the cochlea, is responsible for hearing. Choice B, CN VIII (vestibulocochlear nerve), transmits auditory and balance-related information but is not the physical structure responsible for the sensation of spinning. Choice C, the organ of Corti, is located within the cochlea and is responsible for auditory transduction, not balance sensations.

Question 4 of 5

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o'clock position in each eye. The nurse would:

Correct Answer: C

Rationale: The correct answer is C: document this as an asymmetrical light reflex. This finding indicates an asymmetry in the corneal light reflex, suggesting a possible deviation in eye alignment or muscle weakness. It is essential to document this observation for further evaluation and monitoring. Choice A is incorrect as asymmetry in the light reflex is not a normal finding. Referring for further evaluation (Choice B) would be appropriate if the asymmetry persists or is associated with other concerning symptoms. Performing the confrontation test (Choice D) is not necessary for this specific assessment and finding.

Question 5 of 5

The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?

Correct Answer: D

Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles. Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.

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