ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 2 of 9
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Correct Answer: B
Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.
Question 3 of 9
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. Which of the following would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections. Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong. Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections. Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.
Question 4 of 9
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notes the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:
Correct Answer: B
Rationale: The correct answer is B: hyphema. Hyphema is the presence of blood in the anterior chamber of the eye, which can occur due to trauma like being hit with a baseball bat. This indicates bleeding inside the eye, specifically in the space between the cornea and iris. Hypopyon (A) is the accumulation of white blood cells in the anterior chamber. Corneal abrasion (C) is a scratch on the cornea, not related to blood in the anterior chamber. Iritis (D) is inflammation of the iris, which does not necessarily involve blood in the anterior chamber.
Question 5 of 9
Which of the following signs would the nurse expect to find on assessment of an individual with otitis externa?
Correct Answer: D
Rationale: The correct answer is D: Enlarged regional lymph nodes. In otitis externa, there may be regional lymphadenopathy due to inflammation and infection. Rhinorrhea (A) is associated with upper respiratory infections, not otitis externa. Periorbital edema (B) is seen in conditions like periorbital cellulitis. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa.
Question 6 of 9
Which of the following statements about otoscopic examination of a newborn would be true?
Correct Answer: C
Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.
Question 7 of 9
While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?
Correct Answer: B
Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.
Question 8 of 9
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 9 of 9
The nurse is performing middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and visible landmarks. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.