ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 5
A patient has come in for an examination and states,"I have this spot on my cheek here in front of my ear lobe. The spot seems to be getting bigger and is very tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
Correct Answer: B
Rationale: The correct answer is B: parotid gland. The parotid gland is located in front of the ear lobe, and swelling below the angle of the jaw is a common sign of parotid gland inflammation. The tenderness and increasing size of the spot also point towards a parotid gland issue. The other choices, such as thyroid gland (A), occipital lymph node (C), and submental lymph node (D), are incorrect as they are not typically associated with the specific symptoms described by the patient. It is essential to consider the location and function of each structure to arrive at the correct diagnosis.
Question 2 of 5
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
Correct Answer: C
Rationale: Step 1: The nurse notices an enlarged and thick skull, which are common signs of acromegaly. Step 2: Acromegaly results from excess growth hormone, leading to changes in facial features. Step 3: Coarse facial features such as enlarged nose, lips, and jaw are classic signs of acromegaly. Step 4: Therefore, assessing for coarse facial features is crucial in confirming acromegaly. Summary: A: Exophthalmos is associated with hyperthyroidism, not acromegaly. B: Bowed long bones are seen in conditions like rickets, not acromegaly. D: An acorn-shaped cranium is not a typical feature of acromegaly.
Question 3 of 5
During an examination of a female patient, the nurse observes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
Correct Answer: A
Rationale: The correct answer is A: clumped. Acutely infected lymph nodes typically present as clumped due to inflammation and enlargement of multiple nodes in close proximity. This clustering is a result of the immune response to the infection. Choice B: unilateral is incorrect as lymphadenopathy in acute infection can be unilateral or bilateral. Choice C: firm but freely movable is incorrect as acutely infected lymph nodes are usually tender and may not be freely movable due to inflammation. Choice D: hard and nontender is incorrect as acutely infected lymph nodes are usually tender and may not be hard.
Question 4 of 5
While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes. The nodes are approximately 5 cm in size, round, mobile, and nontender. The nurse suspects that this:
Correct Answer: B
Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.
Question 5 of 5
During a well-baby checkup, the mother expresses concern that her 2-month-old infant is not able to hold her head up when she is pulled to a sitting position. Which of the following responses by the nurse is appropriate?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Head control typically develops around 4 months, so it is normal for a 2-month-old to lack this skill. 2. Reassuring the mother that her baby is within the normal developmental range is important for reducing parental anxiety. 3. Avoiding overly alarming responses helps maintain trust and open communication with the parent. Summary: - Choice B is incorrect as it does not address the mother's concern and may come across as dismissive. - Choice C is incorrect as it may unnecessarily worry the mother and lead to undue stress. - Choice D is incorrect as it introduces a serious and unlikely scenario without evidence at this stage of development.