ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
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 2 of 9
A nurse is assessing a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.
Question 3 of 9
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: C
Rationale: Step 1: Swollen and bleeding gums during pregnancy can be a sign of gingivitis or pregnancy gingivitis. Step 2: Dental check-ups during pregnancy are important to prevent potential complications. Step 3: Referring the woman to a dentist ensures proper evaluation and treatment. Step 4: Dental care is safe during pregnancy, so timely intervention is crucial. Step 5: Option C is correct as it addresses the concern with a proactive approach.
Question 4 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
Question 5 of 9
In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Red glow in pupils indicates a normal reflection off the inner retina known as the red reflex. 2. The red reflex helps to visualize the internal structures of the eye, including the retina. 3. This finding is expected during an ophthalmoscopic examination. 4. No abnormality is suggested by the presence of a red glow in the pupils. Summary of Other Choices: A: Incorrect. Red glow does not indicate an opacity in the lens or cornea. B: Incorrect. Checking the light source is unnecessary as red glow is a normal finding. D: Incorrect. Referral is not needed as red reflex is a normal part of an ophthalmoscopic exam.
Question 6 of 9
What is the primary goal for a client with newly diagnosed diabetes?
Correct Answer: B
Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.
Question 7 of 9
Which of the following assessment findings is most consistent with clubbing of the fingernails?
Correct Answer: D
Rationale: Clubbing of the fingernails is characterized by an increased angle between the nail base and the nail plate (usually 180 degrees or greater) and a spongy texture at the nail base. This is due to underlying tissue changes associated with conditions like lung disease. Choice D is correct as it accurately describes the characteristic findings of clubbing. Choices A, B, and C do not align with clubbing features. Choice A describes tenderness and firmness, not sponginess and increased angle. Choice B mentions a convex profile and ridges, which are not specific to clubbing. Choice C includes an angle of 150 degrees, which is less than the typical angle seen in clubbing.
Question 8 of 9
Which of the following factors should a nurse consider when assessing a patient's risk for developing pressure ulcers?
Correct Answer: A
Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.
Question 9 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.