ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
During an assessment of an 80-year-old patient, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: decreased ability to identify odors. As people age, their sense of smell tends to decline due to changes in the olfactory system. This is a common phenomenon in older adults and can impact their overall quality of life. The other choices are incorrect because hypertrophy of the gums (
A) is not a typical finding in older adults, increased production of saliva (
B) is not directly related to aging, and finer and less prominent nasal hair (
D) is not a definitive characteristic of older age.
Question 2 of 5
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale:
1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity.
2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately.
3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment.
Summary:
A: Shielding the lips while speaking would hinder the patient's ability to hear clearly.
C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test.
D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 3 of 5
The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?
Correct Answer: B
Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.
Question 4 of 5
Which of the following is the best way to palpate the lymph nodes in the neck?
Correct Answer: D
Rationale: The correct answer is D because using the index and middle fingers to palpate with gentle pressure in a rotating pattern allows for a thorough examination of the lymph nodes without causing discomfort or injury. This method helps to assess the size, shape, consistency, and tenderness of the nodes accurately. It also enables the examiner to detect any abnormalities such as enlargement or tenderness.
A is incorrect as using strong pressure can be painful and lead to inaccurate assessment. B is incorrect as strong pressure can be harmful and may not provide the necessary sensitivity to detect abnormalities. C is incorrect as pinching each node can be uncomfortable and may not allow for a systematic examination of the lymph nodes.
Question 5 of 5
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale:
Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms.
Therefore, the correct answer is C: maxillary sinusitis.