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
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 3 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 4 of 9
The nurse has discovered decreased skin turgor in a patient. In which of the following would this be an expected finding?
Correct Answer: C
Rationale: The correct answer is C: In an individual who is severely dehydrated. Decreased skin turgor is a clinical sign of dehydration, indicating loss of skin elasticity due to fluid loss. Severe dehydration leads to decreased skin turgor as the skin loses its ability to recoil when pinched. In cases of severe obesity (choice A), skin turgor is usually normal or increased due to excess adipose tissue. During childhood growth spurts (choice B), skin turgor is typically unaffected. Connective tissue disorders like scleroderma (choice D) can lead to changes in skin texture and appearance, but not necessarily decreased skin turgor.
Question 5 of 9
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: D
Rationale: The correct answer is D. The nurse would want to ask about the number of ear infections the baby has had since birth because aspirin exposure during pregnancy is associated with an increased risk of developing Reye's syndrome, which can lead to recurrent ear infections. This question helps assess the baby's risk for complications related to aspirin exposure. Choices A, B, and C are incorrect as they are not directly related to the potential complications associated with aspirin exposure during pregnancy.
Question 6 of 9
Which of the following is a risk factor for ear infections in young children?
Correct Answer: D
Rationale: The correct answer is D: Second-hand cigarette smoke. Exposure to second-hand smoke can irritate and inflame the lining of the Eustachian tube, making young children more susceptible to ear infections. This is supported by research showing a clear link between exposure to cigarette smoke and increased rates of ear infections in children. Family history (A) may contribute to genetic predisposition but is not a direct risk factor. Air conditioning (B) does not directly cause ear infections. Excessive cerumen (C) can lead to blockages but is not a primary risk factor for infections.
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 temporomandibular joint is just below the temporal artery and anterior to the:
Correct Answer: D
Rationale: The correct answer is D: mandible. The temporomandibular joint is located just below the temporal artery and it connects the mandible (lower jaw) to the temporal bone. This joint allows for movement of the jaw during actions like chewing and speaking. Choices A, B, and C are incorrect because the temporomandibular joint is not located near the hyoid bone (A), the vagus nerve (B), or the tragus of the ear (C). These structures are not directly associated with the temporomandibular joint's anatomical location and function.
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.