ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be:
Correct Answer: D
Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.
Question 2 of 9
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
Correct Answer: A
Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.
Question 3 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 4 of 9
The nurse is assessing a 3-year-old who has been brought to the clinic for"drainage from the nose." On assessment, it is found that there is a purulent, malodorous drainage from the left naris but no drainage from the right naris. The child is afebrile and has no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.
Question 5 of 9
A patient with a middle ear infection asks the nurse,"What does the middle ear do?" The nurse says that the function of the middle ear is to:
Correct Answer: C
Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.
Question 6 of 9
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
Correct Answer: A
Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.
Question 7 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 8 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 9 of 9
A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be:
Correct Answer: D
Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.