ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
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.
Question 2 of 9
The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
Correct Answer: B
Rationale: The correct answer is B: not palpable. In healthy adults, most lymph nodes are not palpable as they are typically small and not easily detectable through touch. This indicates normal lymphatic function and absence of significant inflammation or infection. Choices A, C, and D describe characteristics of abnormal lymph nodes, such as being shotty, large/firm/fixed, or rubbery/discrete/mobile, respectively, which are indicative of pathological conditions like infection, malignancy, or inflammation. Therefore, the absence of palpable lymph nodes in a healthy individual is the expected norm.
Question 3 of 9
A patient has been admitted for severe iron-deficiency anemia. What can the nurse expect to find in the patient's fingernails?
Correct Answer: C
Rationale: The correct answer is C: Spoon nails. In iron-deficiency anemia, the nails may develop a concave or spoon-like shape (koilonychia). This is due to the decreased oxygen supply to the nail bed. The characteristic spoon nails are indicative of severe iron deficiency. Splinter hemorrhages (choice A) are small areas of bleeding under the nails and are more commonly associated with conditions like endocarditis. Paronychia (choice B) is an infection around the nail, not specific to anemia. Beau's lines (choice D) are horizontal depressions in the nails, typically seen after a period of severe illness or stress, rather than specifically in iron-deficiency anemia.
Question 4 of 9
A patient is unable to read the 20/100 line on the Snellen chart. The nurse would:
Correct Answer: A
Rationale: The correct answer is A. Referring the patient to an ophthalmologist or optometrist is the appropriate action because the patient's inability to read the 20/100 line on the Snellen chart suggests significant visual impairment that requires professional evaluation. Options B and C are incorrect as they do not address the underlying cause of the vision issue. Option B focuses on a different method of assessment and does not provide a solution for the patient's visual acuity problem. Option C assumes the patient's vision issue can be corrected by reading glasses, which may not be the case for a 20/100 visual acuity. Option D is also incorrect as it only adjusts the testing distance and does not address the need for a comprehensive evaluation by an eye care specialist.
Question 5 of 9
When a light is directed across the iris of the eye from the temporal side, the examiner is assessing for:
Correct Answer: C
Rationale: The correct answer is C: the presence of shadows, which may indicate glaucoma. When a light is directed across the iris from the temporal side, it helps in evaluating the presence of shadows in the anterior chamber angle, which can suggest a narrow or closed angle glaucoma. This technique is known as transillumination test and is important in detecting potential glaucoma cases. A: Drainage from dacryocystitis is incorrect as it is typically assessed by pressing on the lacrimal sac area to observe for discharge. B: Conjunctivitis over the iris is incorrect as conjunctivitis is an inflammation of the conjunctiva, not the iris. D: A scattered light reflex indicative of cataracts is incorrect as cataracts cause clouding of the lens, not scattering of light across the iris.
Question 6 of 9
Which of the following would the nurse expect to find when examining the eyes of a patient of African descent?
Correct Answer: B
Rationale: The correct answer is B: A dark retinal background. This is because individuals of African descent typically have a higher concentration of melanin in their eyes, resulting in a darker retinal background. This can affect the appearance of the fundus during eye examinations. Incorrect choices: A: Increased night vision - Night vision is not directly influenced by melanin levels in the eyes and is more related to the function of rods and cones in the retina. C: Increased photosensitivity - Melanin provides some protection against UV light, so individuals with darker retinas may have lower photosensitivity. D: Narrowed palpebral fissures - Palpebral fissures refer to the opening between the eyelids and are not typically influenced by melanin levels in the eyes.
Question 7 of 9
The nurse is performing middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and visible landmarks. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.
Question 8 of 9
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 9 of 9
A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know how to prevent it. The nurse instructs her to:
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Rubbing alcohol or 2% acetic acid eardrops help to maintain the pH balance in the ear canal, making it less conducive to bacterial growth. 2. These eardrops also help to dry out excess moisture, reducing the risk of otitis externa. 3. By using these eardrops after every swim, the student can prevent the recurrence of otitis externa. Summary of other choices: A: Using a cotton-tipped swab can push wax deeper into the ear canal, increasing the risk of infection. C: Irrigating the ears can introduce water into the ear canal, potentially worsening the condition. D: Mineral oil and hydrogen peroxide can be harsh on the delicate skin of the ear canal, causing irritation.