ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: increased intracranial pressure. Papilledema is swelling of the optic disc due to increased pressure in the brain. It is a sign of serious conditions like brain tumors, head trauma, or hydrocephalus. The other choices are incorrect because retinal detachment presents with visual disturbances and floaters (A), diabetic retinopathy with retinal damage due to diabetes (B), and acute-angle glaucoma with sudden eye pain and blurred vision (C). Papilledema specifically indicates increased intracranial pressure, making choice D the correct answer.
Question 2 of 9
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _____ and starts the examination by:
Correct Answer: B
Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice D) is not relevant to testing the function of CN XI.
Question 3 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 4 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 5 of 9
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During assessment, the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:
Correct Answer: B
Rationale: The correct answer is B: candidiasis. Candidiasis is a fungal infection caused by Candida albicans, commonly seen in immunocompromised individuals like cancer patients post-chemotherapy. The raw, red, and bleeding areas indicate mucosal irritation, while the white, cheesy coating represents fungal overgrowth. Carcinoma (choice A) refers to cancerous growths, which typically present differently. Leukoplakia (choice C) is a precancerous lesion characterized by white patches, not raw areas with bleeding. Koplik's spots (choice D) are small, white spots seen in the mouth in measles, not indicative of the described findings.
Question 6 of 9
A 65-year-old male has reported a crusty nodule behind the pinna. Over the past 6 months, the nodule has been bleeding intermittently and has not healed. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation would be that this:
Correct Answer: C
Rationale: The correct answer is C because the characteristics described (bleeding, not healing, ulcerated, indurated base) are indicative of a potential carcinoma, such as squamous cell carcinoma. These features raise concerns about malignancy and warrant immediate referral for further evaluation and management. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a smooth, non-ulcerated mass, Darwin's tubercle (B) is a normal anatomical variation behind the ear and not associated with bleeding or ulceration, and a tophus (D) is a deposit of uric acid crystals seen in gout and would not present in this manner.
Question 7 of 9
The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
Correct Answer: A
Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.
Question 8 of 9
The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?
Correct Answer: B
Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.
Question 9 of 9
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How would the nurse proceed?
Correct Answer: C
Rationale: The correct answer is C because the nurse should use the Snellen chart positioned 6.1 m (20 ft) away to assess visual acuity. This is the standard method for testing distance vision. The nurse should ask the patient to read the letters on the chart from the top row down, covering one eye at a time if necessary. This method provides an accurate measurement of visual acuity at a distance. A: Performing the confrontation test assesses visual fields, not visual acuity. B: Using a Jaeger card is for near vision testing, not distance visual acuity. D: Assessing the ability to read newsprint at a close distance does not provide an accurate measurement of visual acuity at a distance.