ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 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 2 of 5
The salivary gland that is located in the cheek in front of the ear is the:
Correct Answer: A
Rationale: The correct answer is A: parotid gland. This gland is located in the cheek in front of the ear. It is the largest salivary gland in the human body. The parotid gland secretes saliva into the mouth through Stenson's duct. The other choices are incorrect because Stenson's gland does not exist, the sublingual gland is located under the tongue, and the submandibular gland is located under the mandible.
Therefore, the parotid gland is the only gland that fits the description given in the question.
Question 3 of 5
An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish blue in colour and has small vesicles. What additional information would the nurse need to know?
Correct Answer: B
Rationale: The correct answer is B: Any recent drainage from the ear. This is crucial because drainage could indicate an infection or other underlying issue causing the auricle symptoms. Hearing changes (option
A) may not be directly related to the auricle findings. Recent trauma (option
C) would be more evident on inspection. Prolonged cold exposure (option
D) is less likely to cause the described symptoms.
Question 4 of 5
Which of the following traditionally used hearing tests have been recently found to yield unreliable data?
Correct Answer: A
Rationale: The correct answer is A: Weber. The Weber test has been found to yield unreliable data recently due to its subjectivity and inconsistency in interpretation. The test involves placing a vibrating tuning fork on the midline of the head to assess lateralization of sound. However, factors like bone conduction and individual perception can influence the results, leading to inaccuracies. Romberg test (
B) evaluates balance, Whisper test (
C) assesses hearing sensitivity, and Audiometer (
D) measures hearing thresholds objectively. These tests are more reliable in providing accurate data compared to the Weber test.
Question 5 of 5
While performing an examination of a 3-year-old with a suspected ear infection, the nurse would:
Correct Answer: D
Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment.
Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis.
Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child.
Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.