ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management.
A: Continuing the examination is not appropriate as the bruit should prompt further investigation.
B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue.
C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.
Question 2 of 5
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. Which of the following would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections.
Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong.
Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections.
Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.
Question 3 of 5
When using an otoscope to assess the nasal cavity, which of the following would the nurse need to do?
Correct Answer: B
Rationale: The correct answer is B. When using an otoscope to assess the nasal cavity, it is crucial to avoid touching the nasal septum with the speculum to prevent discomfort or injury to the patient.
Touching the nasal septum can cause pain and potential damage.
Incorrect
Choices:
A: Inserting the speculum at least 3 cm into the vestibule is not necessary and may cause discomfort or injury to the patient.
C: Displacing the nose to the side being examined is not required and may not provide any additional benefit during the assessment.
D: Keeping the speculum tip medial to avoid touching the floor of the nares is not as critical as avoiding contact with the nasal septum, which is more sensitive and can be easily injured.
Question 4 of 5
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment.
Other choices are incorrect because:
A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario.
B: Cluster headaches typically do not present with fever and neck stiffness.
C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 5 of 5
A very concerned mother is at the clinic with her infant who has a large, soft lump on the side of his head. She tells the nurse that she noticed the lump about 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is:
Correct Answer: C
Rationale: The correct answer is C: cephalhematoma. A cephalhematoma is a collection of blood between a baby's skull and the periosteum, typically occurring due to trauma during birth. In this case, the lump appeared 8 hours after birth, which aligns with the timeline for cephalhematoma development. It is soft because it consists of blood, and it can increase in size as the blood accumulates.
Incorrect
Choices:
A: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, not a collection of blood.
B: Craniosynostosis is the premature fusion of skull bones, leading to an abnormal head shape, not a collection of blood.
D: Caput succedaneum is swelling of the soft tissues of a newborn's scalp due to pressure during delivery, not a collection of blood.