ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
In assessing the sclera of a patient of African descent, which of the following would be an expected finding?
Correct Answer: B
Rationale: The correct answer is B because people of African descent commonly have a pigmented layer near the outer canthus of the lower lid called the "plica semilunaris." This is a normal anatomical variation in this population. Yellow fatty deposits over the cornea (choice
A) are not typical findings in this demographic. Yellow color of the sclera extending up to the iris (choice
C) is not a characteristic feature. The presence of small brown macules on the sclera (choice
D) is also not a common finding in individuals of African descent.
Question 2 of 5
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Correct Answer: B
Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection.
Incorrect choices:
A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media.
C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario.
D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.
Question 3 of 5
While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?
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.
Question 4 of 5
A patient is unable to read the 20/100 line on the Snellen chart. The nurse would:
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.
Question 5 of 5
Which of the following statements about the outer layer of the eye is true?
Correct Answer: C
Rationale: The correct answer is C because the trigeminal (CN V) and the trochlear (CN IV) nerves are indeed stimulated when the outer surface of the eye is stimulated. The trigeminal nerve is responsible for the sensation of touch in the face and controls the muscles involved in chewing. The trochlear nerve controls the superior oblique muscle of the eye, which helps with downward and inward eye movements.
Therefore, when the outer layer of the eye is touched or stimulated, these nerves are activated to convey the sensation to the brain.
Choices A, B, and D are incorrect:
A: The outer layer of the eye is not particularly sensitive to touch compared to other areas like the cornea or conjunctiva.
B: The outer layer of the eye is not darkly pigmented; the pigmented layer is actually the uvea inside the eye.
D: The visual receptive layer of the eye, known as the retina, is located deeper within the eye, not