ATI RN
health assessment practice questions Questions
Question 1 of 9
A patient says that she has recently noticed a lump in the front of her neck below her"Adam's apple" that seems to be getting bigger. During the assessment, the finding that reassures the nurse that this may not be a cancerous thyroid nodule is that the lump (nodule):
Correct Answer: B
Rationale: The correct answer is B: the lump is mobile and not hard. A cancerous thyroid nodule is typically fixed and hard, whereas a noncancerous nodule is more likely to be mobile and soft. This characteristic suggests it may be a benign condition such as a thyroid cyst rather than a malignant tumor. The other choices are incorrect because A: tenderness does not necessarily indicate benignity or malignancy, C: disappearance when smiling is more related to a salivary gland issue, and D: hardness and fixation are more indicative of a potentially cancerous nodule.
Question 2 of 9
A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?
Correct Answer: A
Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.
Question 3 of 9
A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview, she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of the following responses by the nurse uses empathy?
Correct Answer: C
Rationale: The correct answer is C because it reflects empathy by acknowledging the mother's feelings without judgment or personal bias. The nurse shows understanding and compassion by recognizing the difficulty of the situation. Incorrect answer A lacks empathy as it simply restates the mother's feeling without demonstrating understanding. Answer B also lacks empathy as it focuses on the boyfriend's actions rather than the mother's feelings. Answer D shows some empathy by acknowledging the difficulty but fails to address the mother's emotional state directly. In summary, answer C is correct because it shows empathy by acknowledging the mother's emotions and validating her experience without judgment or redirection.
Question 4 of 9
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. Ptosis is:
Correct Answer: C
Rationale: The correct answer is C: drooping of the upper eyelid. Ptosis refers to the drooping of the upper eyelid, which may occur due to weakened eyelid muscles or nerve damage. In this case, the nurse suspects ptosis in the 60-year-old man, which is likely due to age-related muscle weakness. Choice A, a cloudy cornea, is incorrect as it refers to a different eye condition. Choice B, an unequal red reflex, is incorrect as it is related to abnormalities in the retina. Choice D, protruding and bulging eyes, is incorrect as it indicates exophthalmos, a condition typically seen in thyroid eye disease.
Question 5 of 9
What is the most appropriate intervention for a client with acute renal failure?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.
Question 6 of 9
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which of the following statements reflects the nurse's best course of action?
Correct Answer: A
Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.
Question 7 of 9
What is the most important assessment for a client with diabetes and newly diagnosed hypertension?
Correct Answer: B
Rationale: The correct answer is B: Perform a comprehensive physical exam. This is important because it helps assess the overall health status of the client, including cardiovascular risk factors that can affect both diabetes and hypertension. Monitoring blood glucose (A) is important for diabetes management but not specific to newly diagnosed hypertension. Checking for protein in the urine (C) is important for assessing kidney function in diabetes, but not the most crucial assessment for newly diagnosed hypertension. Assessing for urinary retention (D) is not directly related to managing diabetes and hypertension.
Question 8 of 9
The nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:
Correct Answer: C
Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.
Question 9 of 9
A nurse is assessing a patient with a history of diabetes and hypertension. The nurse should monitor for which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Chronic kidney disease (CKD). Patients with diabetes and hypertension are at increased risk for developing CKD due to the damaging effects of high blood sugar and elevated blood pressure on the kidneys. The nurse should monitor for signs and symptoms of kidney dysfunction such as proteinuria, elevated creatinine levels, and decreased glomerular filtration rate. B: Chronic pain is not directly related to the patient's history of diabetes and hypertension. While the patient may experience pain as a result of complications from these conditions, it is not the primary complication to monitor for in this case. C: Hypotension, or low blood pressure, is not a common complication associated with diabetes and hypertension. These conditions typically lead to high blood pressure rather than low blood pressure. D: Sepsis is a serious infection that can occur in any patient, but it is not a direct complication specifically related to diabetes and hypertension. Monitoring for sepsis would be important in a broader context but is not