ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
A nurse is teaching a patient with a history of stroke about reducing the risk of another stroke. Which of the following lifestyle changes should the nurse emphasize?
Correct Answer: D
Rationale: The correct answer is D: All of the above. This is the best choice because reducing the risk of another stroke requires a holistic approach. A: Limiting sodium and cholesterol intake helps manage blood pressure and cholesterol levels, reducing the risk of stroke. B: Increasing physical activity and managing weight can improve cardiovascular health and overall well-being, reducing the risk of stroke. C: Taking prescribed medications regularly, such as blood thinners or antihypertensives, is crucial in preventing another stroke. In summary, all three choices address key risk factors for stroke prevention, making them essential components of a comprehensive stroke prevention plan.
Question 2 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 3 of 9
The nurse is obtaining history for a 3-month-old infant. During the interview, the mother states,"I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: A
Rationale: The correct answer is A because drooling is a common sign of teething in infants. The nurse's response should validate the mother's observation to build trust and rapport. Choice B is incorrect because teething can start as early as 3 months. Choice C is incorrect as drooling is a normal developmental milestone in infants. Choice D is incorrect as infants do not consciously control saliva production.
Question 4 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 5 of 9
What is the primary goal for a client with newly diagnosed diabetes?
Correct Answer: B
Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.
Question 6 of 9
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
Correct Answer: A
Rationale: The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction. Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case. Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case. Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 7 of 9
A nurse is caring for a patient who has been prescribed warfarin. The nurse should monitor the patient for signs of which of the following?
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.
Question 8 of 9
A nurse is teaching a patient with a history of hypertension about lifestyle changes. Which of the following lifestyle modifications should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B because reducing alcohol consumption and limiting sodium intake are both crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can contribute to hypertension. By prioritizing these changes, the patient can better control their blood pressure. Choice A is incorrect because increasing sodium intake can worsen hypertension due to fluid retention. Choice C is incorrect as decreasing physical activity can lead to weight gain and worsen hypertension. Choice D is incorrect as processed foods are often high in sodium and unhealthy fats, which can negatively impact blood pressure.
Question 9 of 9
What is the priority nursing action for a client who is experiencing severe chest pain?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. The priority nursing action for a client experiencing severe chest pain is to administer nitroglycerin to help dilate the blood vessels and improve blood flow to the heart, reducing chest pain. This action helps to address the immediate issue of chest pain and potential heart damage. Administering morphine (B) may be considered if chest pain persists despite nitroglycerin. Administering oxygen (C) can also be helpful but is not the initial priority. Monitoring blood pressure (D) is important but not the most urgent action in this scenario.