ATI RN
health assessment practice questions Questions
Question 1 of 9
A patient has a normal pupillary light reflex. The nurse recognizes this to indicate that:
Correct Answer: D
Rationale: The correct answer is D because a normal pupillary light reflex involves the constriction of both pupils in response to bright light. This reflex is controlled by the autonomic nervous system, specifically the parasympathetic nervous system. When light is detected by the retina, signals are sent to the brain which then triggers the constriction of both pupils to reduce the amount of light entering the eye. Choices A, B, and C are incorrect because they do not accurately describe the pupillary light reflex. Vision convergence, light reflection, and focusing the image at the center of the pupil are not directly related to the pupillary light reflex.
Question 2 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.
Question 3 of 9
In a patient with anisocoria, the nurse would expect to observe:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.
Question 4 of 9
During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.
Question 5 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 6 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 7 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 8 of 9
A mother brings her child in to the clinic for scalp and hair examination. She says that the child has developed irregularly shaped patches on her head with broken-off, stublike hair, and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is:
Correct Answer: D
Rationale: The correct answer is D: trichotillomania, which may be caused by her child habitually twirling her hair in an absent-minded way. Trichotillomania is a psychological disorder where individuals have an irresistible urge to pull out their hair. In this case, the broken-off, stublike hair and irregularly shaped patches on the child's head are indicative of hair pulling rather than a medical condition like folliculitis (choice A), traumatic alopecia (choice B), or tinea capitis (choice C). The child's hair being kept very short does not align with the characteristic of these conditions, making trichotillomania the most likely explanation.
Question 9 of 9
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
Correct Answer: C
Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).