ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
Correct Answer: A
Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice
B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice
C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice
D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.
Question 2 of 5
A visitor from Poland who does not speak English appears somewhat apprehensive while the nurse is examining his neck. He would probably be most comfortable if the nurse were examining his thyroid:
Correct Answer: C
Rationale: The correct answer is C because it demonstrates cultural sensitivity and respect for the patient's comfort. Placing the nurse's thumbs on either side of the trachea and tilting the patient's head forward is a non-threatening and non-invasive approach to examining the thyroid. This position allows the nurse to assess the thyroid gland without causing discomfort or intimidation to the patient.
Choice A is incorrect because having the nurse's hands placed firmly around the neck from behind may be perceived as invasive and threatening to the patient.
Choice B is incorrect because having the nurse's thumbs on the patient's neck with eyes averted toward the ceiling may come across as awkward and unprofessional.
Choice D is incorrect because tilting the patient's head backward can cause discomfort and may not be culturally sensitive as it can be perceived as invasive.
Question 3 of 5
A man comes to the emergency department after he had participated in a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he"can't see well" from his left eye. The physician suspects retinal damage. Signs of retinal detachment include:
Correct Answer: B
Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area.
A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially.
C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field.
D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.
Question 4 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 5 of 5
The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles.
Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.