ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
A male patient with acquired immunodeficiency syndrome (AIDS) has come in for an examination and says,"I think that I have the mumps." The nurse would begin by examining the:
Correct Answer: B
Rationale: The correct answer is B: parotid gland. This is because mumps typically presents with swelling and tenderness of the parotid glands. The nurse should examine the parotid gland first to assess for these characteristic signs of mumps. Examining the thyroid gland (choice A) is not relevant to mumps. Cervical lymph nodes (choice C) may be swollen in various conditions but are not specific to mumps. Lastly, examining the mouth and skin for lesions (choice D) is not the initial priority when suspecting mumps.
Question 2 of 5
When examining children with Down's syndrome (trisomy 21), the nurse looks for the possible presence of:
Correct Answer: C
Rationale: Step 1: Down's syndrome is associated with characteristic physical features. Step 2: One common physical feature is a protruding tongue due to a small oral cavity. Step 3: This is known as macroglossia and is seen in individuals with Down's syndrome. Step 4: Therefore, the nurse looks for a protruding thin tongue in children with Down's syndrome. Summary: A is incorrect because ear dysplasia is not a common feature. B is incorrect as a long, thin neck is not a typical characteristic. D is incorrect because a narrow and raised nasal bridge is not a key feature of Down's syndrome.
Question 3 of 5
The physician has diagnosed a tracheal shift in a patient. The nurse is aware that this means that the patient's trachea is:
Correct Answer: D
Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.
Question 4 of 5
The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
Correct Answer: B
Rationale: The correct answer is B: not palpable. In healthy adults, most lymph nodes are not palpable as they are typically small and not easily detectable through touch. This indicates normal lymphatic function and absence of significant inflammation or infection. Choices A, C, and D describe characteristics of abnormal lymph nodes, such as being shotty, large/firm/fixed, or rubbery/discrete/mobile, respectively, which are indicative of pathological conditions like infection, malignancy, or inflammation. Therefore, the absence of palpable lymph nodes in a healthy individual is the expected norm.
Question 5 of 5
During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management. A: Continuing the examination is not appropriate as the bruit should prompt further investigation. B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue. C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.