The physician has diagnosed a tracheal shift in a patient. The nurse is aware that this means that the patient's trachea is:

Correct Answer: D

Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.

Correct Answer: B

Rationale: The correct answer is B: Lyme disease. The presentation of a red circular rash with central clearing, known as erythema migrans, following a hiking trip in the summer is highly indicative of Lyme disease. The specific distribution of the rash across the midriff and behind the knees aligns with typical areas where the rash appears in Lyme disease cases. This rash is a hallmark sign of early Lyme disease caused by the bacterium Borrelia burgdorferi transmitted through the bite of an infected tick. Other answer choices are incorrect because rubeola presents with a different rash pattern, an allergy to mosquito bites would not typically present in this manner, and Rocky Mountain spotted fever typically presents with a different rash appearance and distribution.

Correct Answer: A

Rationale: The correct answer is A: thyroid gland. Thyroxine is a hormone produced by the thyroid gland. An elevated thyroxine level indicates a potential thyroid gland dysfunction. The nurse would examine the thyroid gland to assess its size, texture, and any signs of abnormalities. Incorrect choices: B: Parotid gland - This gland is responsible for producing saliva, not thyroxine. C: Adrenal gland - Responsible for producing hormones like cortisol and adrenaline, not thyroxine. D: Thyroxine gland - There is no such thing as a "thyroxine gland." Thyroxine is a hormone produced by the thyroid gland.

Correct Answer: A

Rationale: The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns. Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.

Correct Answer: B

Rationale: The correct answer is B: damage to the trigeminal nerve. Trigeminal nerve damage can result in the inability to differentiate between sharp and dull sensations on the face. The trigeminal nerve is responsible for transmitting sensory information from the face to the brain. Bell's palsy (choice A) affects facial muscles, not sensory perception. Frostbite (choice C) typically causes numbness rather than loss of sensation discrimination. Scleroderma (choice D) is a connective tissue disorder that does not directly affect sensory perception on the face.

Correct Answer: D

Rationale: The correct answer is D: Enlarged regional lymph nodes. In otitis externa, there may be regional lymphadenopathy due to inflammation and infection. Rhinorrhea (A) is associated with upper respiratory infections, not otitis externa. Periorbital edema (B) is seen in conditions like periorbital cellulitis. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the concern of a possible perforated eardrum by inquiring about the relationship between ear pain and discharge. This is crucial in assessing the severity of the condition. Choice A is incorrect as it focuses on subjective symptoms not specific to a perforated eardrum. Choice B is irrelevant as it doesn't pertain to the immediate concern. Choice C is also incorrect as it doesn't target the current issue of a potential perforated eardrum. Asking about ear pain and discharge helps determine the likelihood of a perforated eardrum and guides further assessment and care.

Correct Answer: A

Rationale: The correct answer is A. Referring the patient to an ophthalmologist or optometrist is the appropriate action because the patient's inability to read the 20/100 line on the Snellen chart suggests significant visual impairment that requires professional evaluation. Options B and C are incorrect as they do not address the underlying cause of the vision issue. Option B focuses on a different method of assessment and does not provide a solution for the patient's visual acuity problem. Option C assumes the patient's vision issue can be corrected by reading glasses, which may not be the case for a 20/100 visual acuity. Option D is also incorrect as it only adjusts the testing distance and does not address the need for a comprehensive evaluation by an eye care specialist.

Correct Answer: B

Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.