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
A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?
Correct Answer: A
Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.
Question 3 of 9
Which assessment finding indicates a positive response to Heparin therapy?
Correct Answer: B
Rationale: The correct answer is B: increased fibrinogen. Heparin therapy works by inhibiting clot formation by enhancing the activity of antithrombin III, which leads to decreased levels of fibrinogen. Therefore, an increase in fibrinogen levels would indicate a positive response to Heparin therapy. Incorrect choices: A: increased platelet count - Heparin therapy does not typically affect platelet count, so an increase in platelet count would not indicate a positive response to Heparin therapy. C: decreased fibrin split products - Decreased fibrin split products may not necessarily indicate a positive response to Heparin therapy, as other factors can also influence their levels. D: decreased bleeding - While decreased bleeding can be a positive outcome of Heparin therapy, it is not a direct assessment finding that indicates a positive response to the therapy.
Question 4 of 9
A 32-year-old woman is at the clinic for a checkup, and she states,"I have little white bumps in my mouth." During the assessment, the nurse notes that she has a 5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. Which of the following would the nurse tell the patient?
Correct Answer: D
Rationale: The correct answer is D because Fordyce's granules are small, yellow-white or flesh-colored spots that are sebaceous glands and commonly found on the oral mucosa. They are benign and do not require treatment. In this case, the patient's description matches the characteristics of Fordyce's granules. Option A is incorrect because strep throat typically presents with other symptoms like sore throat and fever, not white bumps in the mouth. Option B is incorrect as there is no indication of a serious lesion based on the description given. Option C is incorrect as leukoplakia is a condition associated with chronic irritation, not Fordyce's granules.
Question 5 of 9
The nurse is teaching parents of a newborn about feeding their infant. Which instruction should the nurse include?
Correct Answer: A
Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.
Question 6 of 9
What is the nurse's priority when caring for a client experiencing a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.
Question 7 of 9
Which value should a nurse monitor closely when a client is on TPN?
Correct Answer: C
Rationale: The correct answer is C: Glucose. Total Parenteral Nutrition (TPN) is a form of nutrition delivered directly into the bloodstream, providing all essential nutrients including glucose. Monitoring glucose levels is crucial to prevent hyperglycemia or hypoglycemia. Calcium (A), Magnesium (B), and Cholesterol (D) are not typically monitored closely when a client is on TPN, as they are not directly impacted by TPN administration. Calcium and Magnesium levels are usually monitored for other conditions, and Cholesterol levels are not typically affected by TPN administration.
Question 8 of 9
What is the nurse's first action when a client is experiencing an acute asthma attack?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, bronchodilators are the first-line treatment to quickly relieve bronchospasm and improve airflow. They work by relaxing the muscles around the airways, allowing the client to breathe easier. Administering corticosteroids (choices B and C) is important but typically done after bronchodilators to reduce airway inflammation. Encouraging fluid intake (choice D) is not the priority in an acute asthma attack, as the focus should be on addressing the breathing difficulty promptly.
Question 9 of 9
Which nursing measure is most appropriate to meet the expected outcome of positive body image in a client with Kawasaki disease?
Correct Answer: C
Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.