NR-302 Health Assessment I - Set 4 - Part 1

Correct Answer: Isolate the client and escalate immediately

Marked resistance to flexion with comparatively free rotation is nuchal rigidity, and with fever and headache it suggests meningeal irritation. The nurse begins isolation precautions and escalates without waiting for the rest of the assessment. Option b is incorrect because warmth eases muscular stiffness but does nothing for inflamed meninges. An hour of watchful waiting in bacterial meningitis is an hour of untreated infection crossing into the bloodstream. Option c is incorrect because stretching a neck held rigid by meningeal irritation causes pain and achieves nothing therapeutic. Range of motion is not the problem; the inflammation behind the resistance is the real target. Option d is incorrect because cervical arthritis limits movement in every direction and builds up over years. Sudden resistance to flexion alongside fever and headache is a different story that cannot wait for rounds.

Correct Answer: Otitis media with effusion

Fluid without infection turns the drum amber and dull, pulls it inward so the landmarks stand out, and often leaves a visible fluid line. Painless muffled hearing is the usual complaint. Option a is incorrect because an active infection would bulge the drum, hide the landmarks, and come with fever and abrupt pain. Antibiotics do not speed clearance of the quiet fluid seen here. Option b is incorrect because vigorous crying reddens a drum rather than turning it amber, and it never creates a fluid line. A crying child's drum still moves normally and shows no retraction. Option d is incorrect because keratin debris in a retraction pocket carries foul, dirty yellow grey drainage and progressive hearing loss. No discharge is described, and a simple fluid line does not suggest bone erosion.

Correct Answer: A benign difference needing no further workup

A difference of a millimeter or less with brisk equal reactions and a lifelong history describes physiologic anisocoria, present in about one in five people and requiring documentation rather than investigation. Option b is incorrect because pressure inside the skull declares itself with a pupil that is newly larger and sluggish, usually alongside a falling level of consciousness. Nothing here is new or changing. Option c is incorrect because an oculomotor compression brings ptosis, an eye resting down and out, and a dilated pupil that barely responds. This client's smaller pupil reacts normally and the lids sit level. Option d is incorrect because aging shrinks both pupils together and slows both reactions equally. Age never explains a one sided size difference, so calling this an age change would misfile a lifelong normal variant.

Correct Answer: Keep the child calm and summon immediate help

This picture fits epiglottitis, where any airway manipulation can close the airway completely. The nurse leaves the child upright with the caregiver, avoids distress, offers oxygen if tolerated, and calls for skilled airway help. Option a is incorrect because a tongue blade is forbidden when epiglottitis is suspected. Touching the swollen tissue can trigger complete obstruction, turning a frightening presentation into a respiratory arrest within seconds. Option b is incorrect because the tripod posture is protective. Lying the child down lets the swollen epiglottis fall against the airway opening, and forcing that position also increases the agitation that worsens obstruction. Option d is incorrect because swabbing means entering the very area that must be left alone. Diagnostic sampling can wait until an artificial airway is secured, and streptococcal testing does not explain drooling with stridor.

Correct Answer: Depress the middle third of the tongue

The blade flattens the middle third of the tongue firmly enough to open the view while staying clear of the back of the tongue, where contact sets off the gag reflex. Option a is incorrect because the posterior tongue is precisely the trigger zone. Pressing there produces retching, ends the examination early and makes the client reluctant to cooperate when the nurse tries again. Option b is incorrect because lifting from underneath exposes the floor of the mouth and the ventral tongue. That step matters for cancer screening, yet it does nothing to reveal the tonsils or pharyngeal wall. Option c is incorrect because the blade belongs on the tongue, never on the palate. Touching the soft palate provokes the same reflex the nurse is trying to avoid and blocks the view of the uvula.

Correct Answer: Isthmus barely palpable, lateral lobes not palpable

A normal thyroid is often impalpable. The isthmus may be felt as a soft band over the tracheal rings, while the lateral lobes usually cannot be felt at all in a healthy adult. Option b is incorrect because diffuse smooth enlargement describes a goiter from iodine deficiency, Graves disease, or pregnancy. Feeling only a thin isthmus is the opposite of a gland that has grown outward. Option c is incorrect because a discrete nodule is an abnormal finding that needs thyroid function testing and ultrasound. Nothing described here rises above the smooth soft band expected across the upper tracheal rings. Option d is incorrect because tenderness suggests thyroiditis and bilateral enlargement would be visible on inspection. Charting findings the nurse did not actually feel would misrepresent a gland that examined as normal.

Correct Answer: The thyroid gland or attached tissue

The thyroid is fixed to the trachea and larynx, so it travels upward with a swallow. Any midline mass that rises with water belongs to the gland or is attached to it. Option a is incorrect because lymph nodes have no attachment to the airway and stay put during a swallow. Cervical nodes also sit lateral to the midline, along or beneath the sternomastoid. Option b is incorrect because a lipoma is a soft fatty mass in the posterior triangle behind the sternomastoid. Its position is wrong for this lump, and fat does not ride up with laryngeal movement. Option d is incorrect because branchial cleft cysts appear laterally along the front border of the sternomastoid. A midline cyst that also lifts when the tongue is protruded would instead be thyroglossal.

Correct Answer: Arrange an immediate ophthalmology referral

A white pupillary reflex is never normal, and in an infant it means retinoblastoma until proven otherwise, so this child needs same day specialist evaluation rather than reassurance or a scheduled recheck. Option b is incorrect because a camera flash normally returns the same orange red glow from both eyes. Parents who notice one pale pupil in photographs are often describing the earliest visible sign of a tumor. Option c is incorrect because waiting for the next scheduled visit risks a malignancy that threatens life as well as sight. Retinoblastoma usually appears before age five and is treated on the basis of urgency. Option d is incorrect because shielding the eyes addresses light exposure, which has nothing to do with an abnormal reflection returning from the back of the eye. The finding itself would go unexplained and unreported.

Correct Answer: Possible thyroid carcinoma requiring urgent evaluation

A solitary hard fixed nodule, joined by hoarseness from recurrent laryngeal involvement and dysphagia from local pressure, is the pattern that raises thyroid carcinoma. Function tests and ultrasound follow the referral. Option a is incorrect because a multinodular goiter presents as several soft nodules of differing size within a generally enlarged gland. One stony hard lump in an otherwise normal gland reads very differently. Option b is incorrect because Hashimoto thyroiditis gives a painless firm gland that may feel bumpy overall, and it usually announces itself through hypothyroid symptoms. Hoarseness with a fixed nodule points somewhere far more urgent. Option c is incorrect because aging brings prominent facial bones, sagging skin, and a stiffer cervical spine, not thyroid nodules. No age makes a fixed hard lump in the neck an expected finding.

Correct Answer: The blur is likely a refractive problem

A pinhole admits only central rays that bypass a poorly shaped cornea or lens, so improvement through it points to uncorrected refractive error that glasses can fix rather than to disease inside the eye. Option a is incorrect because retinal damage blocks the image after light has already been focused, so narrowing the beam changes nothing. Acuity that stays flat through the pinhole is what suggests retinal disease. Option b is incorrect because a failing optic nerve degrades the signal on its way to the brain, and no optical trick restores it. Such clients read the same line with or without the occluder. Option d is incorrect because a clouded lens scatters light throughout the pupil, and a small aperture cannot clear that haze. Cataract typically leaves the reading unchanged while adding glare and haloes at night.

Correct Answer: Loss of side vision noticed while walking

Peripheral vision loss is disease, not aging, and is the silent early pattern of open angle glaucoma, so the nurse reports it instead of accepting narrowed side vision as expected in later life. Option b is incorrect because pushing print away is presbyopia, the stiffening lens that stops accommodating from about the fourth decade. Reading glasses correct it, and every adult eventually needs them. Option c is incorrect because lipid at the corneal rim is arcus senilis, benign in later years and separated from the limbus by a clear zone. A lipid profile is checked only in younger adults. Option d is incorrect because the iris stiffens with age, so pupils sit smaller and answer light more slowly. That change explains poor dark adaptation and is managed with better lighting, not with a referral.

Correct Answer: Conductive loss in the left ear

Bone beating air in one ear means the air route is obstructed while the cochlea still works. Residual fluid or ossicular stiffness after infection blocks the conducting path, producing a conductive loss on that side. Option a is incorrect because inner ear damage lowers both routes together and leaves air ahead of bone. A reversed ratio cannot arise from the cochlea, since bone conduction depends on that same structure. Option b is incorrect because a healthy ear hears the fork about twice as long by air as by bone. The left ear reversed that relationship, which places it outside the expected range entirely. Option d is incorrect because the right ear produced the expected pattern, with air outlasting bone. Nothing in the findings implicates the right cochlea, and the client's recent illness involved the opposite middle ear.

Correct Answer: Peritonsillar abscess pushing the uvula across

Pus between the tonsil capsule and the pharyngeal muscles produces one sided pain, trismus, a hot potato voice and drooling, and the swelling shoves the uvula away from the affected side. Option a is incorrect because a viral sore throat spreads across both sides and comes with cough, hoarseness and coryza. It does not push the palate outward on one side or lock the jaw. Option c is incorrect because a vagus palsy shifts the uvula without swelling, drooling or trismus. The palate on the weak side hangs low and fails to rise, and the throat itself looks unremarkable. Option d is incorrect because mononucleosis enlarges both tonsils and brings posterior cervical nodes, deep fatigue and an enlarged spleen. Symmetric swelling does not displace the uvula or prevent the client from opening the mouth.

Correct Answer: The node demands prompt provider evaluation

Supraclavicular nodes drain the thorax and abdomen rather than the head, so any palpable one is significant. On the left this is the Virchow node at the end of the thoracic duct. Option a is incorrect because scalp and ear lymph travels to the occipital, posterior auricular, and preauricular chains high on the head. Nothing above the clavicle sends drainage down into that deep supraclavicular hollow. Option b is incorrect because dental sepsis enlarges submandibular and jugulodigastric nodes along the jaw. This client reports no tooth pain, and the chain involved sits far below any oral drainage route. Option c is incorrect because healthy adults usually have no palpable cervical nodes at all. Small mobile nodes are ordinary in children under about eleven, yet this location is never dismissed at any age.

Correct Answer: Stand behind the client and mask the other ear

Standing about two feet behind or beside the client keeps the lips out of view, and gently occluding the opposite ear stops that side from answering for the ear being tested. Option b is incorrect because letting the client watch the mouth turns the screen into lip reading. A person with real hearing loss can score perfectly this way, and the result means nothing. Option c is incorrect because distance is standardized at roughly two feet; a whisper from across a room is inaudible to normal ears. Leaving the other ear open also lets it hear for both. Option d is incorrect because covering both ears tests neither one. The examiner occludes only the ear not being screened, so each side is checked separately with a different set of numbers and letters.

Correct Answer: Stiffening of the lens with age

Presbyopia is the predictable loss of accommodation as the aging lens loses elasticity, so near print must be pushed farther away to focus while distance vision stays unchanged into the fifth decade. Option a is incorrect because clouded lens protein describes cataract, which blurs vision at every distance and brings glare and haloes at night. This client sees distant objects clearly, so the lens remains clear. Option c is incorrect because a short globe means hyperopia, a structural error carried from childhood rather than something that appears in midlife. Onset in the forties points to lost accommodation instead. Option d is incorrect because peripheral corneal lipid forms arcus senilis, a grey white ring that sits outside the visual axis. It changes appearance only and does not affect how print is focused.

Correct Answer: Place the base on the mastoid process

Rinne begins with bone conduction: the base of the vibrating fork rests on the mastoid until the client says the tone has gone, and only then are the tines moved beside the canal. Option a is incorrect because the air conduction step comes second, immediately after the mastoid tone fades. Starting at the canal removes the comparison the test depends on and gives no usable result. Option b is incorrect because a forehead placement is the Weber maneuver, which asks about lateralization between the ears. Rinne examines one ear on its own, so a midline position would answer a different question. Option c is incorrect because touching the tines to skin damps the vibration and stops the tone early. The examiner holds only the stem, and the cheek carries sound no better than any other soft tissue.

Correct Answer: Occlude one naris and present familiar coffee grounds

Smell is tested one nostril at a time with the eyes closed, using a familiar aromatic that does not irritate. Coffee, vanilla or peppermint identify true olfactory function without triggering pain fibers. Option a is incorrect because alcohol irritates the nasal lining and is sensed through the trigeminal nerve. Testing both sides at once also hides a one-sided loss, since the intact nostril answers for both. Option b is incorrect because salt is a taste stimulus, not a smell stimulus. Taste on the front of the tongue travels with the facial nerve, so a salty solution examines a different pathway entirely. Option d is incorrect because ammonia is a noxious agent that provokes a reflex response even when olfaction is destroyed. Presenting it near the mouth also bypasses the receptors sitting high in the nasal roof.

Correct Answer: A phoria of the left eye

Covering broke fusion and let the resting eye wander off the axis, and the jump back on uncovering marks a latent deviation held in check whenever both eyes are open, which is a phoria. Option a is incorrect because a manifest deviation on the right would have shown itself during the cover phase, when the uncovered right eye jumped to pick up the target. That eye never moved. Option b is incorrect because the left eye held the target whenever both eyes were open, which rules out a constant turn. Only after fusion was broken did it slip off the axis. Option c is incorrect because a weak abducting muscle limits how far the eye travels toward the temple and brings double vision worst in that direction. Cover testing here showed full smooth movement.

Correct Answer: Slip a finger from the sternal notch sideways

Place the index finger in the sternal notch and slip it to each side, comparing the space between the trachea and the sternomastoid. Equal spaces on both sides mean the trachea is midline. Option b is incorrect because shoving the larynx sideways hurts, can trigger coughing, and moves the very structure being located. Position is judged by comparing spaces, never by forcing the airway across the neck. Option c is incorrect because jugular venous filling reflects right sided cardiac pressures and volume status. Distended neck veins may accompany a tension pneumothorax, yet they say nothing about where the airway lies. Option d is incorrect because percussion of the supraclavicular area maps underlying lung tissue rather than a midline structure. Tracheal position is a palpation finding taken directly at the sternal notch.