ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
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 5
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 3 of 5
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.
Question 4 of 5
The temporomandibular joint is just below the temporal artery and anterior to the:
Correct Answer: D
Rationale: The correct answer is D: mandible. The temporomandibular joint is located just below the temporal artery and it connects the mandible (lower jaw) to the temporal bone. This joint allows for movement of the jaw during actions like chewing and speaking. Choices A, B, and C are incorrect because the temporomandibular joint is not located near the hyoid bone (A), the vagus nerve (B), or the tragus of the ear (C). These structures are not directly associated with the temporomandibular joint's anatomical location and function.
Question 5 of 5
A visitor from Poland who does not speak English appears somewhat apprehensive while the nurse is examining his neck. He would probably be most comfortable if the nurse were examining his thyroid:
Correct Answer: C
Rationale: The correct answer is C because it demonstrates cultural sensitivity and respect for the patient's comfort. Placing the nurse's thumbs on either side of the trachea and tilting the patient's head forward is a non-threatening and non-invasive approach to examining the thyroid. This position allows the nurse to assess the thyroid gland without causing discomfort or intimidation to the patient. Choice A is incorrect because having the nurse's hands placed firmly around the neck from behind may be perceived as invasive and threatening to the patient. Choice B is incorrect because having the nurse's thumbs on the patient's neck with eyes averted toward the ceiling may come across as awkward and unprofessional. Choice D is incorrect because tilting the patient's head backward can cause discomfort and may not be culturally sensitive as it can be perceived as invasive.