NR-302 Health Assessment I - Set 4 - Part 2

Correct Answer: Hold the card about 14 inches from your eyes

Near vision is checked with a handheld card held about 14 inches away in good light, with reading glasses worn and each eye covered in turn while the client reads the smallest line. Option a is incorrect because reading glasses stay on for the near card, since the point is to measure corrected near vision. Removing them yields a number no clinician can act on. Option c is incorrect because distance across a room describes Snellen chart testing at 20 feet. A handheld card measures the near range, which is where this client's difficulty with small print sits. Option d is incorrect because leaving both eyes open lets the stronger eye carry the weaker one and hides a one sided problem. Each eye is tested by itself before the two are read together.

Correct Answer: Displace the trachea and palpate during swallowing

Both the anterior and posterior approaches use one maneuver: displace the trachea sideways with one hand and palpate the lobe on the other side while the client swallows a sip of water. Option a is incorrect because breath holding belongs to auscultation of an enlarged gland, where tracheal sounds would drown a soft bruit. Holding the breath does nothing to bring a lobe under the fingers. Option b is incorrect because grasping both lobes together gives no landmark and no lateral movement. The gland is examined one lobe at a time so the nurse can compare size, texture, and nodules. Option d is incorrect because slight extension helps during inspection of the lower neck, yet full extension tightens the strap muscles over the gland. The head should flex forward to slacken them for palpation.

Correct Answer: A benign reactive node from local infection

Tenderness, softness, mobility, and a bilateral distribution in the chain that drains an inflamed pharynx describe reactive lymphadenitis. Nodes swell because the capsule stretches while the node filters organisms from the infected tissue upstream. Option b is incorrect because hardness and fixation describe a node tethered to surrounding tissue by tumor, and this child's nodes glide freely under the skin with an obvious throat infection sitting upstream. Option c is incorrect because lymphoma nodes are classically painless and rubbery, growing steadily over weeks alongside night sweats and weight loss. Tender nodes appearing with a sore throat point elsewhere entirely. Option d is incorrect because matting means separate nodes have fused into one immovable mass. The nurse can outline each of these nodes individually, and small palpable nodes are common in school-age children anyway.

Correct Answer: Constriction of both pupils with inward eye movement

Shifting focus from far to near triggers the near reaction, so the ciliary muscle thickens the lens while both pupils constrict and the eyes converge toward the approaching target. Option a is incorrect because widening pupils and diverging eyes describe what happens when gaze returns to the distant wall. Near focus reverses that pattern, shrinking the pupil to sharpen depth of focus. Option b is incorrect because the near reaction is bilateral and symmetric rather than one sided. A single sluggish pupil suggests an oculomotor nerve problem and would be charted as an abnormal finding. Option c is incorrect because a completely static pupil and unmoving eye mean accommodation failed. Healthy clients show a visible change within seconds, and its absence is documented and reported rather than accepted.

Correct Answer: The submental node behind the mandibular tip

The submental node sits in the midline a few centimeters behind the tip of the mandible and receives lymph from the lower lip, the floor of the mouth, the tongue tip, and the chin. Option a is incorrect because occipital nodes collect lymph from the posterior scalp, so head lice or tinea capitis enlarges them. An oral lesion sends nothing backward over the crown to reach them. Option b is incorrect because the posterior cervical chain runs along the anterior edge of the trapezius and swells in mononucleosis, rubella, or a scalp infection. Mouth lesions drain forward and downward instead. Option d is incorrect because supraclavicular nodes receive drainage from the thorax and abdomen, which is exactly why one is never ignored. A tongue ulcer does not feed that distant collecting route.

Correct Answer: Ask for head turn and shrug against resistance

Strength testing follows range of motion. Turning the head against the nurse's hand and shrugging the shoulders against downward pressure checks the sternomastoid and trapezius, which cranial nerve eleven supplies. Option a is incorrect because a neck is never forced. Active movement performed by the client sets a safe limit, while passive pushing risks injury and is avoided entirely when any trauma is suspected. Option c is incorrect because suspected fracture rules out neck movement altogether. This client denies injury and has already moved freely, so hunting for a fracture answers a question that was never raised. Option d is incorrect because bedside cervical motion is judged by watching for smoothness, symmetry, pain, and crepitus. Precise angles belong to specialist assessment and add nothing to a routine screening examination.

Correct Answer: Macular degeneration affecting central vision

Wavy lines and a central blind spot with mobility intact describe macular breakdown, since the cones that read print sit in the macula while the peripheral retina keeps the client walking safely. Option a is incorrect because raised pressure damage takes the edges of the field first and silently, leaving reading intact until very late. Bumping into objects, not distorted lines, is the complaint it produces. Option b is incorrect because a clouding lens blurs everything at once and adds glare and haloes around headlights at night. Lines stay straight through a cataract, since nothing is pulling the retina out of shape. Option d is incorrect because a separating retina announces itself suddenly with a shower of floaters, flashes of light, and a dark curtain sweeping across the field. This client describes a slow central change.

Correct Answer: Arrange removal of the impacted cerumen

Hardened wax filling the canal is a reversible conductive cause of reduced hearing, and it is common in older adults. Clearing it first prevents a hearing problem from being recorded as confusion. Option a is incorrect because charting a cognitive label before checking whether the resident can hear the question is a well known error. The finding in the canals offers a simpler explanation that must be excluded. Option c is incorrect because raising the voice distorts speech sounds and can be painful when loudness grows abnormally fast. Volume also does nothing about the wax physically blocking sound from reaching the drum. Option d is incorrect because amplification is prescribed after audiological evaluation, not chosen at the bedside. Fitting an aid over an occluded canal would amplify sound into a blockage and leave the resident no better off.

Correct Answer: A tense bulging fontanelle that does not pulsate

A fontanelle that bulges and feels tense while the infant is upright, calm, and quiet points to raised intracranial pressure from meningitis, hydrocephalus, or bleeding. That finding is escalated at once. Option a is incorrect because the diamond shaped anterior fontanelle stays open far longer, closing anywhere between about nine months and two years. At five months an open soft spot on top is entirely expected. Option b is incorrect because the triangular posterior fontanelle normally seals by one to two months of age. Closure at two months sits comfortably inside the expected timetable and needs no report. Option c is incorrect because the trend on the growth chart matters more than any single value. An occipitofrontal measurement following its own curve is exactly what steady brain growth looks like.

Correct Answer: The posterior scalp and hairline

Lymph moves in one direction, so an enlarged node points upstream to the region it drains. Occipital nodes take drainage from the posterior scalp, where lice, tinea capitis, or a scalp infection may sit. Option b is incorrect because tonsillar and pharyngeal lymph collects in the jugulodigastric node under the angle of the mandible. A throat source would enlarge that node, not one sitting at the occiput. Option c is incorrect because drainage from the lower lip, floor of the mouth, and tongue tip runs to the submental node in the midline behind the mandible. That chain lies nowhere near the occiput. Option d is incorrect because eyelid and conjunctival lymph drains to the preauricular node sitting just in front of the tragus. Viral conjunctivitis classically enlarges that node, which the nurse would feel beside the ear.

Correct Answer: The tongue protrudes midline with equal strength

Tongue movement and strength belong to the twelfth cranial nerve. An intact nerve brings the tongue straight out in the midline, moves it fully to each side, and presses equally into both cheeks. Option a is incorrect because drifting to one side is a hallmark of hypoglossal injury. The stronger half pushes the tongue across, so it points toward the damaged side and calls for a swallow assessment. Option b is incorrect because visible twitching of the muscle surface signals denervation rather than health. Fasciculations accompany atrophy in lower motor neuron disease and would prompt referral, not documentation as a normal screen. Option c is incorrect because a slick, shiny, beefy red surface describes atrophic glossitis. That appearance follows loss of papillae from vitamin B twelve, folate or iron deficiency and has no bearing on motor testing.

Correct Answer: Support the airway and alert the provider now

A pupil that becomes larger and sluggish alongside a falling level of consciousness signals rising pressure with impending herniation, so the nurse secures airway, breathing, and circulation and summons help immediately. Option a is incorrect because waiting an hour allows brain tissue to shift further against the third cranial nerve. Damage from herniation accumulates by the minute, and delay costs the client whatever time treatment needs. Option c is incorrect because charting is necessary but never sufficient when a neurological sign is changing in front of the nurse. Finishing the rest of the head to toe survey leaves the emergency unaddressed. Option d is incorrect because repeating the light test in a dim room refines a routine assessment rather than answering an emergency. The finding is already clear, and confirming it again wastes minutes the brain does not have.

Correct Answer: Pearly grey, translucent, intact, and slightly concave

A healthy drum is pearly grey and translucent enough to show the malleus behind it, sits flat with a slight inward pull at the umbo, and has no hole or fluid. Option b is incorrect because an amber, opaque, retracted drum points to fluid sitting behind it from eustachian tube blockage. That picture belongs to otitis media with effusion rather than to a healthy ear. Option c is incorrect because redness with a convex contour and lost mobility describes an acutely infected middle ear. Pus behind the membrane pushes it outward, and the normal drum never looks inflamed like this. Option d is incorrect because dense white thickening suggests scarring from old infections, and bulging signals pressure from within. Neither belongs in a description of an unremarkable membrane, though tympanosclerosis itself is usually harmless.

Correct Answer: Reduced neck rotation with crepitus and stiffness

Degenerative change narrows the cervical intervertebral spaces with age, producing stiffness, crepitus, and reduced range of motion. The nurse moves an older neck gently and never forces it toward the limit. Option a is incorrect because a node in that hollow drains the chest and abdomen, so age never explains it. Hardness and fixation push the finding further toward malignancy rather than toward normal aging. Option b is incorrect because the trachea should sit midline at every age, with equal spaces on either side. Displacement means something is pushing or pulling it and calls for prompt evaluation. Option d is incorrect because thyroid nodules are abnormal whenever they appear, and a solitary hard one raises concern for carcinoma. Every nodule earns function testing and ultrasound regardless of the client's years.

Correct Answer: The crossing fibers at the optic chiasm

Fibers from the nasal half of each retina cross at the chiasm and carry the temporal fields, so a mass pressing there wipes out both outer halves and produces bitemporal hemianopsia. Option a is incorrect because damage in front of the chiasm costs vision in one eye only. This client has a matching outer loss in both eyes, which no single retinal lesion can explain. Option b is incorrect because a tract lesion carries the whole opposite half of the world, giving homonymous hemianopsia with the same side lost in both eyes. Stroke and tumor cause that pattern. Option c is incorrect because occipital injury from a posterior cerebral artery stroke also produces a same sided field loss, often with central vision spared. Outer halves on both sides point forward to the chiasm.

Correct Answer: Darken the room and choose a distant fixation point

Dimming the room lets the pupils enlarge so a change is visible, and fixing on something far away keeps accommodation from constricting them, leaving the light reflex clean to observe. Option a is incorrect because watching the penlight pulls the eyes to a near target and triggers the accommodation response. The constriction seen would then belong to near focus rather than to light. Option c is incorrect because light aimed along the line of sight dazzles the client and hides the moment of constriction. The beam comes in from the side so the reaction can be timed. Option d is incorrect because drops paralyze the very response being measured and rule out later pupil checks. Pharmacologic dilation is not part of routine nursing assessment and can provoke angle closure in susceptible eyes.

Correct Answer: The cover and uncover test

Covering one eye breaks fusion, which is the only way to expose a small deviation the penlight reflection cannot show, and it also separates a manifest turn from a latent one. Option b is incorrect because tracking through an H pattern maps muscle strength and cranial nerve function, showing where an eye fails to travel. It says nothing about alignment while the child looks straight ahead. Option c is incorrect because comparing peripheral fields screens the visual pathway from retina to occipital cortex. A child with normal side vision can still have eyes that fail to point at the same target. Option d is incorrect because rhythmically moving a light between the eyes hunts for an afferent pupil defect from optic nerve or retinal disease. Pupil behavior tells the nurse nothing about muscle balance.

Correct Answer: Brace the otoscope hand against the child's head

Resting the ulnar side of the examining hand on the head means the otoscope travels with any sudden movement, so the speculum cannot be driven into the canal wall or the drum. Option a is incorrect because speed replaces control with luck. Rushing the tip inward during a struggle is precisely how canal skin gets abraded and how the membrane gets scratched by an unbraced instrument. Option b is incorrect because free arms let a frightened child bat at the otoscope. The caregiver hold that works keeps the arms secured against the body while the head rests against the chest. Option d is incorrect because a small tip narrows the view and encourages deeper insertion, which is the opposite of what a moving child needs. Speculum size is chosen for fit, not for restlessness.

Correct Answer: A benign normal variant needing no treatment

Fading on stretching identifies leukoedema, a harmless variant seen more often in Black clients. It cannot be scraped off and is not raised, so it needs correct naming rather than treatment or follow up. Option b is incorrect because thrush forms curd like plaques that lift off under a blade and expose a raw red surface. Nothing about this diffuse veil behaves that way, and the client has no symptoms. Option c is incorrect because leukoplakia is a thick raised plaque with sharp borders that stays visible when the cheek is pulled taut. Treating this variant as premalignant leads to needless alarm and an unnecessary procedure. Option d is incorrect because deficiency states show themselves on the tongue and lip corners, not as a filmy sheet on the cheeks. A smooth beefy red tongue or cracked commissures would prompt those blood tests.

Correct Answer: Use the right eye and the right hand

The examiner matches side to side, holding the scope in the right hand and looking with the right eye for the client's right eye, which keeps both heads clear of each other. Option a is incorrect because crossing sides puts the examiner nose to nose with the client and blocks the view. The left eye and left hand are saved for the client's left eye. Option b is incorrect because a bright room keeps the pupil small and leaves almost no opening to look through. Dimming the lights widens the pupil naturally without any need for drops. Option c is incorrect because the macula is dense with cones and floods with light, causing watering and reflex closure. It is inspected last, after the disc, the vessels, and the background.