ATI RN
Health Assessment Practice Questions Questions
Question 1 of 5
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 2 of 5
A woman has come to the clinic to seek help for a substance use problem. She admits to using cocaine just before coming to the clinic. Which of the following describes what the nurse may find when examining this woman?
Correct Answer: A
Rationale: The correct answer is A. Cocaine is a stimulant drug that typically leads to symptoms such as dilated pupils, pacing, and psychomotor agitation. Dilated pupils occur due to increased catecholamines. Pacing and psychomotor agitation are common behaviors associated with cocaine use. Unsteady gait and aggressiveness (Option B) are more characteristic of alcohol intoxication. Pupil constriction, lethargy, apathy, and dysphoria (Option C) are typical symptoms of opioid use. Constricted pupils, euphoria, and decreased temperature (Option D) are more indicative of opioid use as well.
Question 3 of 5
During assessment, the nurse notices that the skin of a patient of Asian descent is yellowish brown in colour. The skin on the hard and soft palate is, however, pink in colour. From this finding, the nurse could probably rule out:
Correct Answer: B
Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.
Question 4 of 5
A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:
Correct Answer: B
Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.
Question 5 of 5
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.