ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 5
A patient reports a severe throbbing headache in the frontotemporal area of his head that he experienced while studying for an examination, He says that the headache was somewhat relieved when he lay down. He tells the nurse that his mother also used to get these headaches. The nurse suspects that he may be suffering from:
Correct Answer: D
Rationale: The correct answer is D: migraine headaches. The patient's symptoms of severe throbbing headache in the frontotemporal area, triggered by stress (studying for an exam), partially relieved by lying down, and family history of similar headaches are indicative of migraines. Migraines commonly present with these characteristics, often exacerbated by stress and have a genetic component. A: Hypertension does not typically present with throbbing headaches in a specific area or relief with lying down. B: Cluster headaches are characterized by severe, unilateral headaches around the eye area, not frontotemporal. C: Tension headaches usually present as dull, constant pressure-type headaches, not throbbing, and do not have the familial pattern described by the patient.
Question 2 of 5
The nurse is preparing to auscultate a patient's enlarged thyroid for the presence of a bruit. A bruit is a:
Correct Answer: C
Rationale: The correct answer is C because a bruit is a soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. This sound indicates turbulent blood flow, often due to a narrowed or blocked artery. Using the bell of the stethoscope allows for better detection of low-frequency sounds like bruits. A is incorrect because a low gurgling sound is not indicative of a bruit. B is incorrect because a loud, whooshing, blowing sound is not characteristic of a bruit. D is incorrect because a high-pitched tinkling sound is not typically associated with a bruit. In summary, the correct answer is C because it accurately describes the characteristics of a bruit, while the other choices do not align with the typical sound of a bruit.
Question 3 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 4 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 5 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.