ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 5
Which of the following is an expected normal finding in the diagnostic positions test?
Correct Answer: D
Rationale: The correct answer is D: A slight amount of lid lag when moving the eyes from a superior position to an inferior position. In the diagnostic positions test, when the eyes move from an extreme superior position to an inferior position, a slight amount of lid lag is expected due to the normal anatomical structure and mechanics of the eye muscles and eyelids. This lag is a normal finding and not indicative of any underlying pathology.
Rationale:
A: Convergence of vision in both eyes is not a normal finding in the diagnostic positions test as convergence refers to the inward movement of both eyes towards each other to maintain single binocular vision.
B: Parallel movement of both eyes is not a specific finding in the diagnostic positions test. The test is designed to assess the movement of the eyes in different directions.
C: Nystagmus in extreme superior gaze is not a normal finding and indicates an abnormality in eye movement coordination, not an expected finding in the diagnostic positions test.
Question 2 of 5
Which of the following physiological changes is responsible for presbyopia?
Correct Answer: B
Rationale: The correct answer is B, loss of lens elasticity. Presbyopia is the age-related loss of near vision due to the lens becoming less flexible, making it harder to focus on close objects. With aging, the lens loses its ability to change shape, affecting near vision. Other choices are incorrect because presbyopia is primarily related to changes in the lens, not the cornea (
A), adaptation to darkness (
C), or distance vision abilities (
D).
Question 3 of 5
The nurse notes the presence of periorbital edema when performing eye assessment on a 70-year-old patient. The nurse will:
Correct Answer: B
Rationale: The correct answer is B: suspect that the patient has hyperthyroidism. Periorbital edema is a common sign of hyperthyroidism due to the accumulation of fluid in the tissues around the eyes. By suspecting hyperthyroidism, the nurse can further assess for other associated symptoms and recommend appropriate diagnostic tests.
Choice A (check for the presence of exophthalmos) is incorrect because exophthalmos refers to bulging eyes, which may be present in hyperthyroidism but is not directly related to periorbital edema.
Choice C (ask the patient if he or she has a history of heart failure) is incorrect as periorbital edema is not typically associated with heart failure, which usually presents with generalized edema.
Choice D (assess for blepharitis) is incorrect because while blepharitis can cause eyelid inflammation, it is not typically associated with periorbital edema seen in hyper
Question 4 of 5
A patient has had a"terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior.
Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.
Question 5 of 5
During an ophthalmoscopic examination of a patient, the examiner notes areas of exudate that look like"cotton wool" or fluffy grey-white cumulus clouds. Which of the possible problems below does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Diabetes. The presence of "cotton wool" or fluffy grey-white cumulus clouds on ophthalmoscopic examination indicates retinal nerve fiber layer infarcts due to microvascular damage, which is a common finding in diabetic retinopathy. This occurs due to ischemia and subsequent axonal swelling. In diabetes, hyperglycemia can lead to damage in the blood vessels supplying the retina, resulting in microaneurysms, hemorrhages, exudates, and ultimately vision loss if left untreated.
Summary of other choices:
B: Hyperthyroidism - This condition primarily affects the thyroid gland and does not directly cause the characteristic retinal findings described.
C: Glaucoma - Glaucoma is a condition characterized by increased intraocular pressure and optic nerve damage, which does not typically present with the specific retinal findings mentioned.
D: Hypotension - Low blood pressure may lead to retinal artery occlusion or ischemic optic neuropathy,