ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
A father brings his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been occurring at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant?
Correct Answer: A
Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.
Question 2 of 5
What would be a normal finding when assessing the lacrimal apparatus during an eye examination?
Correct Answer: A
Rationale: The correct answer is A: The presence of tears along the inner canthus. This is a normal finding during an eye examination as tears are produced by the lacrimal gland and drain into the nasolacrimal duct, which exits at the inner canthus. This indicates proper tear production and drainage.
Incorrect choices:
B: A blocked nasolacrimal duct in a newborn infant - This would present as excessive tearing and discharge.
C: A slight swelling over the upper lid and along the bony orbit if the patient has a cold - This could indicate inflammation due to infection.
D: The absence of drainage from the puncta when the inner orbital rim is pressed - This would suggest an issue with the lacrimal drainage system.
Question 3 of 5
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull.
A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease.
B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease.
C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.
Question 4 of 5
The nurse is testing the hearing of a 78-year-old man. Which of the following age-related hearing changes should the nurse keep in mind? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Age-related hearing loss begins in the mid-40s. This is because presbycusis, or age-related hearing loss, typically starts around the mid-40s due to natural aging processes affecting the inner ear.
Choice B is incorrect as the progression of hearing loss can vary, being gradual for some individuals but not necessarily slow for everyone.
Choice C is incorrect as high-frequency tone loss, not low-frequency, is commonly associated with aging.
Choice D is incorrect as difficulty hearing consonants is more related to specific types of hearing loss, not solely age-related changes.
Question 5 of 5
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (
A) is a soft tissue dangling at the back of the throat, the palate (
B) is the roof of the mouth, and papillae (
C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.