ATI RN
health assessment practice questions Questions
Question 1 of 9
A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?
Correct Answer: D
Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.
Question 2 of 9
During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small, compared with an enlarged cranium. On further examination, the nurse also notes dilated scalp veins and downcast, or"setting sun," eyes. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.
Question 3 of 9
A patient says that she has recently noticed a lump in the front of her neck below her"Adam's apple" that seems to be getting bigger. During the assessment, the finding that reassures the nurse that this may not be a cancerous thyroid nodule is that the lump (nodule):
Correct Answer: B
Rationale: The correct answer is B: the lump is mobile and not hard. A cancerous thyroid nodule is typically fixed and hard, whereas a noncancerous nodule is more likely to be mobile and soft. This characteristic suggests it may be a benign condition such as a thyroid cyst rather than a malignant tumor. The other choices are incorrect because A: tenderness does not necessarily indicate benignity or malignancy, C: disappearance when smiling is more related to a salivary gland issue, and D: hardness and fixation are more indicative of a potentially cancerous nodule.
Question 4 of 9
A patient is at the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
Correct Answer: C
Rationale: The correct answer is C: Bell's palsy. Bell's palsy is characterized by sudden weakness or paralysis of the facial muscles, resulting in drooping of the face, inability to raise the eyebrow or close the eye, and difficulty with facial expressions and functions like whistling. In this case, the patient's symptoms of left-sided facial paralysis point towards Bell's palsy as the likely diagnosis. Cushing's syndrome (A) is a hormonal disorder, Parkinson's syndrome (B) is a neurodegenerative disorder affecting movement, and a cerebrovascular accident (D) typically presents with more generalized neurological deficits rather than isolated facial paralysis.
Question 5 of 9
When assessing the tongue of an adult, an abnormal finding would be:
Correct Answer: A
Rationale: The correct answer is A because a smooth, glossy dorsal surface of the tongue is abnormal in adults and may indicate glossitis or nutritional deficiencies. B is incorrect as a thin white coating is normal. Raised papillae (choice C) may indicate transient lingual papillitis but are not typically abnormal. Visible venous patterns (choice D) are normal on the ventral surface.
Question 6 of 9
A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. Which of the following about this technique is true?
Correct Answer: D
Rationale: The correct answer is D because asking the patient to hold his nose and swallow causes the eustachian tube to open, equalizing pressure in the middle ear. This action will cause the eardrum to bulge slightly outward, making landmarks more visible. Choice A is incorrect as age alone does not preclude the use of this technique. Choice B is incorrect because this technique is not primarily used for assessing otitis media. Choice C is incorrect as it is not specific to upper respiratory infections.
Question 7 of 9
When examining a patient's eyes, the nurse knows that stimulation of the sympathetic branch of the autonomic nervous system:
Correct Answer: C
Rationale: The correct answer is C because stimulation of the sympathetic branch of the autonomic nervous system results in the elevation of the eyelid (ptosis) and dilation of the pupil (mydriasis). This is due to the action of the dilator pupillae muscle and the superior tarsal muscle. Pupillary constriction (choice A) is controlled by the parasympathetic branch via the sphincter pupillae muscle. Adjusting the eye for near vision (choice B) is controlled by the ciliary muscle, which is under parasympathetic control, not sympathetic. Contraction of the ciliary body (choice D) is also controlled by the parasympathetic system for accommodation of near vision, not the sympathetic system.
Question 8 of 9
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess will be:
Correct Answer: C
Rationale: The correct answer is C: at the level of the C7 vertebra. The vertebra prominens refers to the spinous process of the C7 vertebra, which is the most prominent bony landmark at the base of the neck. Assessing this area allows the nurse to accurately locate and evaluate tenderness reported by the physician. Choices A, B, and D are incorrect as they do not correspond to the location of the vertebra prominens. Option A is too high, above the diaphragm; option B is too low, lateral to the knee cap; and option D is too low, at the level of the T11 vertebra.
Question 9 of 9
A mother who has brought her newborn infant for assessment tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, the baby straightens out the arm and leg on the same side and flexes the opposite arm and leg. After confirming this on examination, the nurse would tell the mother that this is:
Correct Answer: C
Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.