ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: damage to the trigeminal nerve. Trigeminal nerve damage can result in the inability to differentiate between sharp and dull sensations on the face. The trigeminal nerve is responsible for transmitting sensory information from the face to the brain. Bell's palsy (choice A) affects facial muscles, not sensory perception. Frostbite (choice C) typically causes numbness rather than loss of sensation discrimination. Scleroderma (choice D) is a connective tissue disorder that does not directly affect sensory perception on the face.
Question 2 of 5
A mother brings her newborn in for an assessment and asks,"Is there something wrong with my baby? His head seems so big." Which of the following does the nurse know about the relative proportions of the head and trunk in the newborn?
Correct Answer: A
Rationale: The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns. Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.
Question 3 of 5
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 4 of 5
A male patient with acquired immunodeficiency syndrome (AIDS) has come in for an examination and says,"I think that I have the mumps." The nurse would begin by examining the:
Correct Answer: B
Rationale: The correct answer is B: parotid gland. This is because mumps typically presents with swelling and tenderness of the parotid glands. The nurse should examine the parotid gland first to assess for these characteristic signs of mumps. Examining the thyroid gland (choice A) is not relevant to mumps. Cervical lymph nodes (choice C) may be swollen in various conditions but are not specific to mumps. Lastly, examining the mouth and skin for lesions (choice D) is not the initial priority when suspecting mumps.
Question 5 of 5
A very concerned mother is at the clinic with her infant who has a large, soft lump on the side of his head. She tells the nurse that she noticed the lump about 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is:
Correct Answer: C
Rationale: The correct answer is C: cephalhematoma. A cephalhematoma is a collection of blood between a baby's skull and the periosteum, typically occurring due to trauma during birth. In this case, the lump appeared 8 hours after birth, which aligns with the timeline for cephalhematoma development. It is soft because it consists of blood, and it can increase in size as the blood accumulates. Incorrect Choices: A: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, not a collection of blood. B: Craniosynostosis is the premature fusion of skull bones, leading to an abnormal head shape, not a collection of blood. D: Caput succedaneum is swelling of the soft tissues of a newborn's scalp due to pressure during delivery, not a collection of blood.