ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
A patient with a middle ear infection asks the nurse,"What does the middle ear do?" The nurse says that the function of the middle ear is to:
Correct Answer: C
Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.
Question 2 of 9
Which of the following is the best way to palpate the lymph nodes in the neck?
Correct Answer: D
Rationale: The correct answer is D because using the index and middle fingers to palpate with gentle pressure in a rotating pattern allows for a thorough examination of the lymph nodes without causing discomfort or injury. This method helps to assess the size, shape, consistency, and tenderness of the nodes accurately. It also enables the examiner to detect any abnormalities such as enlargement or tenderness. A is incorrect as using strong pressure can be painful and lead to inaccurate assessment. B is incorrect as strong pressure can be harmful and may not provide the necessary sensitivity to detect abnormalities. C is incorrect as pinching each node can be uncomfortable and may not allow for a systematic examination of the lymph nodes.
Question 3 of 9
While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
Correct Answer: D
Rationale: The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period. Rationale: 1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth. 2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube. 3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making. 4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being. Incorrect Choices: A: "You're right, bottles make
Question 4 of 9
The nurse is testing the hearing of a 78-year-old man. Which of the following age-related hearing changes should the nurse keep in mind? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Age-related hearing loss begins in the mid-40s. This is because presbycusis, or age-related hearing loss, typically starts around the mid-40s due to natural aging processes affecting the inner ear. Choice B is incorrect as the progression of hearing loss can vary, being gradual for some individuals but not necessarily slow for everyone. Choice C is incorrect as high-frequency tone loss, not low-frequency, is commonly associated with aging. Choice D is incorrect as difficulty hearing consonants is more related to specific types of hearing loss, not solely age-related changes.
Question 5 of 9
A patient's medical record describes a lesion that is confluent in nature. On examination, the nurse would expect to find:
Correct Answer: A
Rationale: The correct answer is A: lesions that run together. Confluent lesions refer to merging or blending of individual lesions to form a larger lesion. This indicates a continuous area of involvement on the skin. Choices B, C, and D do not accurately describe confluent lesions as they refer to different patterns of lesion distribution such as annular, linear, or grouped. The key to identifying confluent lesions is the concept of merging or running together, which is best represented by choice A.
Question 6 of 9
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
Correct Answer: A
Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.
Question 7 of 9
When the retina is examined, which of the following is considered a normal finding?
Correct Answer: A
Rationale: The correct answer is A: An optic disc that is a yellow-orange colour. This is a normal finding because the optic disc typically appears yellow-orange due to the presence of nerve fibers. The yellow-orange color is due to the absence of blood vessels in this area. This is a normal anatomical characteristic of the optic disc. Option B is incorrect because blurred optic disc margins can indicate pathology such as papilledema. Option C is incorrect because the presence of pigmented crescents in the macular area can indicate a condition like myopic degeneration, not a normal finding. Option D is incorrect because the macula is normally located temporally, not nasally, to the optic disc.
Question 8 of 9
A patient with a middle ear infection asks the nurse,"What does the middle ear do?" The nurse says that the function of the middle ear is to:
Correct Answer: C
Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.
Question 9 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.