ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 5
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 2 of 5
The nurse is doing an oral assessment on a 40-year-old patient of African descent and notes the presence of a 1-cm, nontender, greyish-white lesion on the left buccal mucosa. Which of the following about this lesion is true?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Leukoedema is a common benign condition in individuals of African descent. 2. Leukoedema presents as greyish-white lesions on the buccal mucosa. 3. It is typically asymptomatic and does not require treatment. 4. Leukoedema is not associated with any serious health concerns. Summary of why other choices are incorrect: B. Hyperpigmentation would present as dark patches, not greyish-white lesions. C. Torus palatinus is a bony growth on the hard palate, not a mucosal lesion. D. Cancerous lesions typically have different characteristics and would require further investigation.
Question 3 of 5
The nurse is preparing to auscultate a patient's enlarged thyroid for the presence of a bruit. A bruit is a:
Correct Answer: C
Rationale: The correct answer is C because a bruit is a soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. This sound indicates turbulent blood flow, often due to a narrowed or blocked artery. Using the bell of the stethoscope allows for better detection of low-frequency sounds like bruits. A is incorrect because a low gurgling sound is not indicative of a bruit. B is incorrect because a loud, whooshing, blowing sound is not characteristic of a bruit. D is incorrect because a high-pitched tinkling sound is not typically associated with a bruit. In summary, the correct answer is C because it accurately describes the characteristics of a bruit, while the other choices do not align with the typical sound of a bruit.
Question 4 of 5
A hospitalized patient who has received numerous antibiotics is being assessed by the nurse, who notes that his tongue appears black and hairy. Which of the following would the nurse say to the patient?
Correct Answer: C
Rationale: The correct answer is C: "This is a fungal infection caused by all the antibiotics you've received." The black, hairy tongue is a known side effect of prolonged antibiotic use, which disrupts the balance of normal oral flora and predisposes to fungal overgrowth, specifically of the yeast Candida. Antibiotics can eliminate the competing bacteria that normally keep Candida in check. Therefore, the patient's symptoms are most likely due to a fungal infection related to antibiotic therapy, rather than a bacterial issue or temporary overgrowth of hair. Biopsy is not necessary as the condition is commonly seen in this context and can be managed with appropriate treatment for fungal overgrowth.
Question 5 of 5
During an ophthalmoscopic examination of a patient, the examiner notes areas of exudate that look like"cotton wool" or fluffy grey-white cumulus clouds. Which of the possible problems below does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Diabetes. The presence of "cotton wool" or fluffy grey-white cumulus clouds on ophthalmoscopic examination indicates retinal nerve fiber layer infarcts due to microvascular damage, which is a common finding in diabetic retinopathy. This occurs due to ischemia and subsequent axonal swelling. In diabetes, hyperglycemia can lead to damage in the blood vessels supplying the retina, resulting in microaneurysms, hemorrhages, exudates, and ultimately vision loss if left untreated. Summary of other choices: B: Hyperthyroidism - This condition primarily affects the thyroid gland and does not directly cause the characteristic retinal findings described. C: Glaucoma - Glaucoma is a condition characterized by increased intraocular pressure and optic nerve damage, which does not typically present with the specific retinal findings mentioned. D: Hypotension - Low blood pressure may lead to retinal artery occlusion or ischemic optic neuropathy,