ATI RN
health assessment practice questions Questions
Question 1 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.
Question 2 of 9
What should be the nurse's first action when a client develops a fever after surgery?
Correct Answer: A
Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.
Question 3 of 9
A 31-year-old patient tells the nurse that he is experiencing a progressive loss of hearing. He says that it does seem to help when people speak more loudly or if he turns up the volume. The most likely cause of his hearing loss is:
Correct Answer: A
Rationale: The correct answer is A: otosclerosis. Otosclerosis is a condition where abnormal bone growth in the middle ear causes hearing loss. In this case, the patient's symptoms of progressive hearing loss improving with louder sounds suggest conductive hearing loss, which is commonly seen in otosclerosis. Other choices are incorrect because presbycusis is age-related hearing loss, trauma to the bones would typically result in sudden hearing loss, and frequent ear infections are more likely to cause temporary hearing loss rather than progressive loss.
Question 4 of 9
The nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:
Correct Answer: C
Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.
Question 5 of 9
During ear examination, the patient reports that he is hears a buzzing sound that is"driving me crazy!" The nurse recognizes that this symptom is:
Correct Answer: C
Rationale: The correct answer is C: tinnitus. Tinnitus is the perception of sound without an external source, often described as ringing, buzzing, or hissing. In this case, the patient reporting a buzzing sound aligns with tinnitus. Vertigo (A) is a sensation of spinning or dizziness, not a sound perception. Pruritus (B) is itching, not a sound perception. Cholesteatoma (D) is a benign growth in the middle ear, not specifically related to sound perception. Therefore, tinnitus is the most appropriate choice based on the patient's symptom of hearing a buzzing sound.
Question 6 of 9
A patient comes into the emergency department after an accident at work. He had not been wearing safety glasses, and a machine had blown dust into his eyes. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered corneal abrasion?
Correct Answer: D
Rationale: The correct answer is D. A shattered look to the light rays reflecting off the cornea indicates corneal abrasion. When the cornea is scratched or abraded, light rays reflecting off it appear shattered due to irregularities on the corneal surface. This is a classic sign of corneal abrasion. A: Smooth and clear corneas (incorrect) - This would not indicate corneal abrasion as abrasions cause irregularities on the corneal surface. B: Opacity of the lens behind the cornea (incorrect) - This suggests a different issue related to the lens, not corneal abrasion. C: Bleeding from the areas across the cornea (incorrect) - This suggests a more severe injury like a corneal laceration, not a simple abrasion. In summary, choice D is correct as the shattered look of light rays is a characteristic finding in corneal abrasion, while the other choices do not
Question 7 of 9
During an assessment, a patient says that she was diagnosed with open-angle glaucoma 2 years ago. There are various types of glaucoma, such as open-angle glaucoma and closed-angle glaucoma. Which of the following are characteristics of open-angle glaucoma? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: It is the most common type of glaucoma. Open-angle glaucoma is indeed the most common type, accounting for about 90% of all glaucoma cases. In open-angle glaucoma, the drainage angle of the eye remains open, but the trabecular meshwork becomes blocked over time. This leads to increased intraocular pressure, which can damage the optic nerve and result in vision loss. A, C, and D are incorrect: A: The symptoms mentioned (sensitivity to light, nausea, halos around lights) are more commonly associated with acute angle-closure glaucoma, not open-angle glaucoma. C: Immediate treatment is not necessarily needed for open-angle glaucoma as it progresses slowly, and treatment can vary based on the severity of the condition. D: Vision loss in open-angle glaucoma typically starts with the loss of peripheral vision, not central vision.
Question 8 of 9
A nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every time the patient feels short of breath, even without a flare-up, is not the recommended practice for managing COPD. Inhalers should be used as prescribed by the healthcare provider or only during exacerbations. Here's the rationale: 1. Using the inhaler excessively can lead to overuse of medication and potential side effects. 2. It is important for patients to differentiate between regular management and acute exacerbations. 3. Monitoring oxygen levels (choice D) is essential for COPD management. 4. Quitting smoking (choice A) and deep breathing exercises (choice B) are positive self-management strategies for COPD.
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.