ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 9
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in history-taking would be:
Correct Answer: D
Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important as dryness in the mouth can be a side effect of certain medications used to manage hypertension and chronic lung disease. Dry mouth can lead to oral health issues and impact the patient's overall well-being. A: "Do you use a fluoride supplement?" is not directly relevant to the patient's medical history of hypertension and lung disease. B: "Have you had tonsillitis in the last year?" is not as crucial as dry mouth in relation to managing hypertension and lung disease. C: "At what age did you get your first tooth?" is not pertinent to the current medical conditions and management of hypertension and lung disease. In summary, the question about dryness in the mouth is the most relevant as it pertains to potential medication side effects and oral health implications for the patient with hypertension and chronic lung disease.
Question 2 of 9
Which of the following cranial nerves (CNs) is responsible for conducting nerve impulses to the brain from the organ of Corti?
Correct Answer: C
Rationale: The correct answer is C: CN VIII. The vestibulocochlear nerve (CN VIII) is responsible for conducting nerve impulses from the organ of Corti in the inner ear to the brain. This nerve specifically carries auditory information to the brainstem and auditory cortex for processing. Choice A (CN I) is incorrect as it is the olfactory nerve responsible for smell. Choice B (CN III) is incorrect as it is the oculomotor nerve responsible for eye movement. Choice D (CN XI) is incorrect as it is the accessory nerve responsible for neck and shoulder movements.
Question 3 of 9
During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?
Correct Answer: D
Rationale: The presence of black and white dots on the tympanic membrane and ear canal wall during an otoscopic examination suggests a yeast or fungal infection. This is because yeast or fungal infections commonly present as white or black dots in the ear canal. Malignancy would typically manifest as abnormal growths or masses, not dots. Viral infections usually do not present as specific dots on the tympanic membrane. Blood in the middle ear would appear as red or pinkish fluid behind the eardrum, not as black and white dots. Therefore, the correct answer is D: Yeast or fungal infection.
Question 4 of 9
When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices bilateral pitting edema in the lower legs. The skin is puffy and tight but of normal colour. There is no increased redness or tenderness, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.
Question 5 of 9
When assessing inflammation in a dark-skinned person, the nurse may need to:
Correct Answer: C
Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.
Question 6 of 9
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?
Correct Answer: C
Rationale: The correct answer is C: Erythematous scaly patch with sharp margins in the sacral area. In patients with AIDS, this presentation is most likely indicative of a common opportunistic infection called tinea corporis. This fungal infection often presents as erythematous scaly patches with well-defined borders. The location in the sacral area is also common due to the warm and moist environment. Choice A, tinea capitis, is a fungal infection of the scalp and is not typically associated with AIDS. Choice B describes a presentation more indicative of a condition like seborrheic dermatitis rather than an AIDS-related skin manifestation. Choice D describes a presentation more typical of tinea corporis, which is not commonly seen in the axilla region in patients with AIDS.
Question 7 of 9
While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes. The nodes are approximately 5 cm in size, round, mobile, and nontender. The nurse suspects that this:
Correct Answer: B
Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.
Question 8 of 9
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 9 of 9
A semiconscious woman is brought to the emergency department after being found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red colour. The nurse suspects that this colouring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloring in a semiconscious woman found on the floor in her kitchen indicates carbon monoxide poisoning. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red coloration. Polycythemia would result in a purplish-red color, carotenemia in a yellow-orange hue, and uremia in a pale or yellowish complexion. Therefore, the correct answer is B, as it aligns with the clinical presentation and pathophysiology of carbon monoxide poisoning.