ATI RN
health assessment practice questions Questions
Question 1 of 5
A 92-year-old patient has had a stroke, and the right side of his face is drooping. What else would the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. In a stroke patient with right-sided facial drooping, dysphagia is highly likely due to the involvement of the facial nerve, leading to difficulty swallowing. Epistaxis (A) is nosebleeds, agenesis (B) is the absence of a body part, and xerostomia (D) is dry mouth, which are not directly related to facial drooping in stroke patients. Dysphagia is a common complication post-stroke due to impaired muscle control, making it the most likely concern for the nurse to suspect in this case.
Question 2 of 5
A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?
Correct Answer: D
Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.
Question 3 of 5
A mother who has brought her newborn infant for assessment tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, the baby straightens out the arm and leg on the same side and flexes the opposite arm and leg. After confirming this on examination, the nurse would tell the mother that this is:
Correct Answer: C
Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.
Question 4 of 5
In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Red glow in pupils indicates a normal reflection off the inner retina known as the red reflex. 2. The red reflex helps to visualize the internal structures of the eye, including the retina. 3. This finding is expected during an ophthalmoscopic examination. 4. No abnormality is suggested by the presence of a red glow in the pupils. Summary of Other Choices: A: Incorrect. Red glow does not indicate an opacity in the lens or cornea. B: Incorrect. Checking the light source is unnecessary as red glow is a normal finding. D: Incorrect. Referral is not needed as red reflex is a normal part of an ophthalmoscopic exam.
Question 5 of 5
Which of the following about a newborn infant is true?
Correct Answer: C
Rationale: The correct answer is C because the frontal sinuses are indeed fairly well developed at birth. This is true as the frontal sinuses start developing around the age of 7-8 years but are present in a rudimentary form at birth. This is because the frontal bone grows rapidly in the first few years of life, allowing for the development of the frontal sinuses. Choice A is incorrect because the sphenoid sinuses are not at full size at birth; they continue to develop throughout childhood. Choice B is incorrect as the maxillary sinuses reach full size around the teenage years, not after puberty. Choice D is incorrect as the frontal sinuses are also present at birth, along with the maxillary and ethmoid sinuses.