ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 9
A woman in her second trimester of pregnancy mentions that since becoming pregnant she has had"more nosebleeds than ever." The nurse recognizes that this is due to:
Correct Answer: B
Rationale: The correct answer is B: increased vascularity in the upper respiratory tract as a result of the pregnancy. During pregnancy, hormonal changes lead to increased blood flow in the body, including the nasal passages, causing them to become more sensitive and prone to bleeding. This explains why the woman is experiencing more nosebleeds. Incorrect Choices: A: coagulation problems in the patient - This is incorrect as pregnancy is associated with hypercoagulability rather than coagulation problems. C: increased susceptibility to colds and nasal irritation - While pregnancy can lower immunity, this does not directly cause nosebleeds. D: inappropriate use of nasal sprays - This is not relevant to the situation described and does not explain the increased nosebleeds due to pregnancy.
Question 2 of 9
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct?
Correct Answer: C
Rationale: The correct answer is C: The purpose of cerumen is to protect and lubricate the ear. Cerumen, commonly known as earwax, acts as a natural barrier to prevent dust, debris, and microorganisms from entering the ear canal. It also helps to lubricate the skin in the ear canal and prevent dryness and itching. Choice A is incorrect because sticky, honey-colored cerumen is not necessarily a sign of infection; it can occur due to various factors. Choice B is incorrect as the presence of cerumen does not solely indicate poor hygiene; everyone produces earwax regardless of hygiene practices. Choice D is incorrect as cerumen can sometimes block the ear canal and impair sound transmission rather than aid it.
Question 3 of 9
Which of the following is an expected normal finding in the diagnostic positions test?
Correct Answer: D
Rationale: The correct answer is D: A slight amount of lid lag when moving the eyes from a superior position to an inferior position. In the diagnostic positions test, when the eyes move from an extreme superior position to an inferior position, a slight amount of lid lag is expected due to the normal anatomical structure and mechanics of the eye muscles and eyelids. This lag is a normal finding and not indicative of any underlying pathology. Rationale: A: Convergence of vision in both eyes is not a normal finding in the diagnostic positions test as convergence refers to the inward movement of both eyes towards each other to maintain single binocular vision. B: Parallel movement of both eyes is not a specific finding in the diagnostic positions test. The test is designed to assess the movement of the eyes in different directions. C: Nystagmus in extreme superior gaze is not a normal finding and indicates an abnormality in eye movement coordination, not an expected finding in the diagnostic positions test.
Question 4 of 9
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in history-taking would be:
Correct Answer: D
Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important as dryness in the mouth can be a side effect of certain medications used to manage hypertension and chronic lung disease. Dry mouth can lead to oral health issues and impact the patient's overall well-being. A: "Do you use a fluoride supplement?" is not directly relevant to the patient's medical history of hypertension and lung disease. B: "Have you had tonsillitis in the last year?" is not as crucial as dry mouth in relation to managing hypertension and lung disease. C: "At what age did you get your first tooth?" is not pertinent to the current medical conditions and management of hypertension and lung disease. In summary, the question about dryness in the mouth is the most relevant as it pertains to potential medication side effects and oral health implications for the patient with hypertension and chronic lung disease.
Question 5 of 9
When assessing pupillary light reflex, which of the following techniques should the nurse use?
Correct Answer: C
Rationale: The correct answer is C because shining a light across the pupil from the side allows for both direct (ipsilateral) and consensual (contralateral) pupillary constriction to be observed. This technique helps to assess the integrity of the cranial nerves involved in the pupillary light reflex (CN II and III). Direct constriction occurs in the eye exposed to the light, while consensual constriction occurs in the opposite eye. This comprehensive assessment ensures that both pupils are responding appropriately to light stimulation, providing a more accurate evaluation of the reflex. Choice A is incorrect because inspecting for pupillary constriction from directly in front may not adequately assess for consensual constriction in the opposite eye. Choice B is incorrect as asking the patient to follow the penlight in eight directions does not specifically target the pupillary light reflex. Choice D is incorrect as it focuses on accommodation rather than the pupillary light reflex.
Question 6 of 9
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that:
Correct Answer: B
Rationale: The correct answer is B: the patient can read at 6.1 m (20 ft) what a person with normal vision can read at 9.1 m (30 ft). This is because the Snellen notation 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet. This ratio signifies the patient's visual acuity compared to a person with normal vision. The other choices are incorrect as they do not accurately interpret the Snellen notation or misinterpret the distance at which the patient can read the eye chart.
Question 7 of 9
While performing an examination of a 3-year-old with a suspected ear infection, the nurse would:
Correct Answer: D
Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment. Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child. Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.
Question 8 of 9
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
Correct Answer: C
Rationale: Step 1: The nurse notices an enlarged and thick skull, which are common signs of acromegaly. Step 2: Acromegaly results from excess growth hormone, leading to changes in facial features. Step 3: Coarse facial features such as enlarged nose, lips, and jaw are classic signs of acromegaly. Step 4: Therefore, assessing for coarse facial features is crucial in confirming acromegaly. Summary: A: Exophthalmos is associated with hyperthyroidism, not acromegaly. B: Bowed long bones are seen in conditions like rickets, not acromegaly. D: An acorn-shaped cranium is not a typical feature of acromegaly.
Question 9 of 9
A patient has had a"terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior. Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.