ATI RN
nclex physical and health assessment questions Questions
Question 1 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 2 of 9
Which of the following is the best way to palpate the lymph nodes in the neck?
Correct Answer: D
Rationale: The correct answer is D because using the index and middle fingers to palpate with gentle pressure in a rotating pattern allows for a thorough examination of the lymph nodes without causing discomfort or injury. This method helps to assess the size, shape, consistency, and tenderness of the nodes accurately. It also enables the examiner to detect any abnormalities such as enlargement or tenderness. A is incorrect as using strong pressure can be painful and lead to inaccurate assessment. B is incorrect as strong pressure can be harmful and may not provide the necessary sensitivity to detect abnormalities. C is incorrect as pinching each node can be uncomfortable and may not allow for a systematic examination of the lymph nodes.
Question 3 of 9
The nurse is conducting a hearing assessment using the Romberg test. The nurse is assessing for:
Correct Answer: D
Rationale: The Romberg test assesses the maintenance of standing balance by having the patient stand with feet together, arms at the sides, and eyes closed. If the patient sways or loses balance, it may indicate proprioceptive deficits. Conductive hearing loss (A) is related to sound transmission issues in the outer or middle ear, not balance. Lateralization of hearing (B) relates to distinguishing sound direction. Sensorineural loss (C) involves inner ear or auditory nerve damage, not balance. Therefore, the correct answer is D as the Romberg test specifically evaluates standing balance.
Question 4 of 9
During an assessment of an 80-year-old patient, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: decreased ability to identify odors. As people age, their sense of smell tends to decline due to changes in the olfactory system. This is a common phenomenon in older adults and can impact their overall quality of life. The other choices are incorrect because hypertrophy of the gums (A) is not a typical finding in older adults, increased production of saliva (B) is not directly related to aging, and finer and less prominent nasal hair (D) is not a definitive characteristic of older age.
Question 5 of 9
The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles. Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.
Question 6 of 9
Which of the following best describes the test to assess the function of cranial nerve (CN) X?
Correct Answer: D
Rationale: The correct answer is D because cranial nerve X, also known as the vagus nerve, controls the movement of the soft palate and uvula. Asking the patient to say "ahhh" assesses the function of CN X as the soft palate and uvula should elevate symmetrically. A: Observing the patient's ability to articulate specific words does not specifically test CN X function. B: Assessing movement of the hard palate and uvula with the gag reflex primarily tests CN IX (glossopharyngeal nerve). C: Having the patient stick out the tongue and observing for tremors or pulling to one side primarily tests CN XII (hypoglossal nerve).
Question 7 of 9
A mother is concerned that her 18-month-old already has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D. At 18 months, it is expected for a child to have erupted around 16 deciduous teeth. The rationale for this answer is based on dental development milestones. By age 3, most children should have their full set of 20 primary teeth. Therefore, the nurse should inform the mother that it is normal for an 18-month-old to have around 16 teeth. Choice A is incorrect as comparing the mother's teeth at that age is irrelevant to the child's dental development. Choice B is incorrect because all 20 deciduous teeth should be present by age 3, not 4. Choice C is incorrect as having 12 teeth at 18 months is below the expected number of erupted teeth for that age.
Question 8 of 9
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: D
Rationale: The correct answer is D. The nurse would want to ask about the number of ear infections the baby has had since birth because aspirin exposure during pregnancy is associated with an increased risk of developing Reye's syndrome, which can lead to recurrent ear infections. This question helps assess the baby's risk for complications related to aspirin exposure. Choices A, B, and C are incorrect as they are not directly related to the potential complications associated with aspirin exposure during pregnancy.
Question 9 of 9
A patient presents with excruciating pain on one side of his head, especially around his eye, forehead, and cheek, that occurs once or twice each day and lasts about 30 minutes to 2 hours. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: cluster headaches. Cluster headaches are characterized by excruciating pain on one side of the head, often around the eye, forehead, and cheek. They occur once or twice each day and last for a relatively short duration of 30 minutes to 2 hours. This pattern of symptoms aligns with the typical presentation of cluster headaches. Incorrect Choices: A: Hypertension is unlikely to present with such specific unilateral head pain patterns and timing. C: Tension headaches typically present with more diffuse, mild to moderate pain and are not typically associated with eye, forehead, or cheek pain. D: Migraine headaches usually last longer than 2 hours and are commonly associated with other symptoms such as nausea, vomiting, and sensitivity to light and sound.