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
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (A) is a soft tissue dangling at the back of the throat, the palate (B) is the roof of the mouth, and papillae (C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.
Question 3 of 9
A woman is at the clinic for a checkup and says,"My eyes have gotten puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:
Correct Answer: C
Rationale: The correct answer is C: myxedema. This is a classic presentation of hypothyroidism, specifically myxedema, characterized by puffy eyes, coarse hair, and dry skin. The thyroid hormone deficiency leads to decreased metabolic activity, causing these symptoms. Cachexia (A) is severe muscle wasting seen in conditions like cancer. Cretinism (B) is congenital hypothyroidism leading to mental retardation. Scleroderma (D) is a connective tissue disorder causing skin thickening, not typically associated with these symptoms.
Question 4 of 9
The nurse is assessing a 3-year-old who has been brought to the clinic for"drainage from the nose." On assessment, it is found that there is a purulent, malodorous drainage from the left naris but no drainage from the right naris. The child is afebrile and has no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.
Question 5 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 6 of 9
During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
Correct Answer: D
Rationale: The correct answer is D: the bony labyrinth. The bony labyrinth is the portion of the inner ear that includes the vestibular system responsible for balance and spatial orientation. This system detects rotational movements and contributes to the sensation of vertigo or spinning. Choice A, the cochlea, is responsible for hearing. Choice B, CN VIII (vestibulocochlear nerve), transmits auditory and balance-related information but is not the physical structure responsible for the sensation of spinning. Choice C, the organ of Corti, is located within the cochlea and is responsible for auditory transduction, not balance sensations.
Question 7 of 9
During the ear examination of an 80-year-old patient, which of the following would be a normal finding?
Correct Answer: C
Rationale: The correct answer is C: A thin, translucent membrane. In elderly patients, the tympanic membrane tends to become thinner and more translucent due to age-related changes. This is considered a normal finding as it is a common occurrence in older individuals. The other choices are incorrect because: A) Loss of high-tone frequency hearing is not a normal finding in an ear examination of an elderly patient, as age-related hearing loss typically affects high frequencies. B) Increased elasticity of the pinna is not a common age-related change and may indicate a different issue. D) A shiny pink tympanic membrane is not a typical finding in an elderly patient and could suggest inflammation or infection instead of a normal age-related change.
Question 8 of 9
Intraocular pressure is determined by the:
Correct Answer: D
Rationale: The correct answer is D because intraocular pressure is primarily determined by the amount of aqueous humor produced and the resistance to its outflow at the angle of the anterior chamber. When there is an imbalance in the production and outflow of aqueous humor, it can lead to an increase in intraocular pressure, which can result in conditions like glaucoma. Choices A, B, and C are incorrect because they do not directly influence intraocular pressure. The thickness or bulging of the lens (A) is related to accommodation for near vision, the posterior chamber accommodating fluid (B) is not a primary factor in determining intraocular pressure, and the contraction of the ciliary body (C) affects the shape of the lens for focusing rather than intraocular pressure regulation.
Question 9 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.