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
Jaundice is manifested by a yellow skin colour, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice?
Correct Answer: B
Rationale: Step 1: Jaundice is characterized by a yellow skin color due to elevated bilirubin levels. Step 2: Yellow color extending up to the iris indicates systemic jaundice, involving the whole body. Step 3: Yellow patches throughout the sclera (Choice A) may not indicate systemic jaundice. Step 4: Skin appearing yellow under low light (Choice C) may not be specific to jaundice. Step 5: Yellow deposits on palms and soles (Choice D) are not typical signs of jaundice. Therefore, Choice B is correct as it reflects systemic jaundice, while the other choices do not fully align with the manifestation of true jaundice.
Question 4 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 5 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.
Question 6 of 9
During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
Correct Answer: D
Rationale: The correct answer is D: the bony labyrinth. The bony labyrinth is the portion of the inner ear that includes the vestibular system responsible for balance and spatial orientation. This system detects rotational movements and contributes to the sensation of vertigo or spinning. Choice A, the cochlea, is responsible for hearing. Choice B, CN VIII (vestibulocochlear nerve), transmits auditory and balance-related information but is not the physical structure responsible for the sensation of spinning. Choice C, the organ of Corti, is located within the cochlea and is responsible for auditory transduction, not balance sensations.
Question 7 of 9
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the:
Correct Answer: B
Rationale: The correct answer is B: supraclavicular area. Enlarged submental lymph nodes can indicate a systemic issue. Assessing the supraclavicular area is important as it contains Virchow's node, which may indicate malignancy or metastasis. Choices A, C, and D are incorrect as they do not specifically target the area most likely to reveal significant findings related to the enlarged submental lymph nodes.
Question 8 of 9
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During assessment, the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:
Correct Answer: B
Rationale: The correct answer is B: candidiasis. Candidiasis is a fungal infection caused by Candida albicans, commonly seen in immunocompromised individuals like cancer patients post-chemotherapy. The raw, red, and bleeding areas indicate mucosal irritation, while the white, cheesy coating represents fungal overgrowth. Carcinoma (choice A) refers to cancerous growths, which typically present differently. Leukoplakia (choice C) is a precancerous lesion characterized by white patches, not raw areas with bleeding. Koplik's spots (choice D) are small, white spots seen in the mouth in measles, not indicative of the described findings.
Question 9 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.