ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
A 70-year-old patient reports to the nurse that he is having trouble hearing, especially when he is in large groups. He says he"can't always tell where the sound is coming from" and the words often sound"mixed up." What might the nurse suspect as the cause for this?
Correct Answer: C
Rationale: The correct answer is C: Degeneration of nerves in the inner ear. This is likely the cause of the patient's hearing difficulties, as age-related degeneration of nerves in the inner ear can lead to difficulty distinguishing sounds and determining their direction. Atrophy of the apocrine glands (Choice A) and cilia becoming coarse and stiff (Choice B) are not related to hearing loss. Scarring of the tympanic membrane (Choice D) would affect sound conduction but not the perception of sound direction and clarity.
Question 2 of 9
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale: Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms. Therefore, the correct answer is C: maxillary sinusitis.
Question 3 of 9
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 9
A 65-year-old male has reported a crusty nodule behind the pinna. Over the past 6 months, the nodule has been bleeding intermittently and has not healed. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation would be that this:
Correct Answer: C
Rationale: The correct answer is C because the characteristics described (bleeding, not healing, ulcerated, indurated base) are indicative of a potential carcinoma, such as squamous cell carcinoma. These features raise concerns about malignancy and warrant immediate referral for further evaluation and management. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a smooth, non-ulcerated mass, Darwin's tubercle (B) is a normal anatomical variation behind the ear and not associated with bleeding or ulceration, and a tophus (D) is a deposit of uric acid crystals seen in gout and would not present in this manner.
Question 5 of 9
Intraocular pressure is determined by the:
Correct Answer: D
Rationale: The correct answer is D because intraocular pressure is primarily determined by the amount of aqueous humor produced and the resistance to its outflow at the angle of the anterior chamber. When there is an imbalance in the production and outflow of aqueous humor, it can lead to an increase in intraocular pressure, which can result in conditions like glaucoma. Choices A, B, and C are incorrect because they do not directly influence intraocular pressure. The thickness or bulging of the lens (A) is related to accommodation for near vision, the posterior chamber accommodating fluid (B) is not a primary factor in determining intraocular pressure, and the contraction of the ciliary body (C) affects the shape of the lens for focusing rather than intraocular pressure regulation.
Question 6 of 9
The nurse is assessing a 3-year-old who has been brought to the clinic for"drainage from the nose." On assessment, it is found that there is a purulent, malodorous drainage from the left naris but no drainage from the right naris. The child is afebrile and has no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.
Question 7 of 9
A 70-year-old patient reports to the nurse that he is having trouble hearing, especially when he is in large groups. He says he"can't always tell where the sound is coming from" and the words often sound"mixed up." What might the nurse suspect as the cause for this?
Correct Answer: C
Rationale: The correct answer is C: Degeneration of nerves in the inner ear. This is likely the cause of the patient's hearing difficulties, as age-related degeneration of nerves in the inner ear can lead to difficulty distinguishing sounds and determining their direction. Atrophy of the apocrine glands (Choice A) and cilia becoming coarse and stiff (Choice B) are not related to hearing loss. Scarring of the tympanic membrane (Choice D) would affect sound conduction but not the perception of sound direction and clarity.
Question 8 of 9
During the ear examination of an 80-year-old patient, which of the following would be a normal finding?
Correct Answer: C
Rationale: The correct answer is C: A thin, translucent membrane. In elderly patients, the tympanic membrane tends to become thinner and more translucent due to age-related changes. This is considered a normal finding as it is a common occurrence in older individuals. The other choices are incorrect because: A) Loss of high-tone frequency hearing is not a normal finding in an ear examination of an elderly patient, as age-related hearing loss typically affects high frequencies. B) Increased elasticity of the pinna is not a common age-related change and may indicate a different issue. D) A shiny pink tympanic membrane is not a typical finding in an elderly patient and could suggest inflammation or infection instead of a normal age-related change.
Question 9 of 9
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _____ and starts the examination by:
Correct Answer: B
Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice D) is not relevant to testing the function of CN XI.