ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
During the assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is indicative of:
Correct Answer: A
Rationale: The dry mucosa and deep fissures in the tongue indicate dehydration in the patient. Dehydration causes decreased saliva production, leading to dry mouth and tongue fissures. This is a common symptom of dehydration. The lack of moisture in the oral cavity can result in these physical signs. The other choices are incorrect because irritation by gastric juices typically presents with other symptoms, a normal oral condition would not show these specific findings, and side effects of nausea medication would not directly cause dry mucosa and deep fissures in the tongue. Therefore, the correct answer is A: dehydration.
Question 2 of 5
While performing a mouth assessment on a patient, the nurse notices a 1-cm ulceration that is crusted and has an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to obtain?
Correct Answer: B
Rationale: The correct answer is B: When the patient first noticed the lesion. This information is crucial for determining the duration of the ulceration, aiding in diagnosing potential causes like trauma or infections. Nutritional status (Choice A) may not be directly related to the specific lesion. Whether the patient has had a recent cold (Choice C) is less relevant unless there are other symptoms present. Exposure to sick animals (Choice D) is not pertinent to the mouth ulceration. Therefore, obtaining information on when the patient first noticed the lesion is the most important for proper assessment and treatment planning.
Question 3 of 5
The nurse is assessing a patient with a history of intravenous drug abuse. While assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:
Correct Answer: A
Rationale: The correct answer is A: acquired immunodeficiency syndrome (AIDS). The dark red confluent macule on the hard palate is known as Kaposi's sarcoma, a common manifestation of AIDS. This lesion is caused by Human Herpesvirus 8 and is often seen in patients with compromised immune systems. Measles (B) typically presents with a rash, not a dark red macule. Leukemia (C) does not typically manifest as a dark red macule in the mouth. Carcinoma (D) refers to cancer and would present differently than Kaposi's sarcoma. In summary, the presence of a dark red confluent macule on the hard palate in a patient with a history of intravenous drug abuse is highly suggestive of AIDS, specifically Kaposi's sarcoma.
Question 4 of 5
When examining the nares of a 45-year-old patient who complains of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notes the following: pale, swollen turbinates and clear rhinorrhea. Which of the following is most likely the cause?
Correct Answer: C
Rationale: The correct answer is C: Allergic rhinitis. The patient's symptoms of rhinorrhea, itching, and sneezing, along with pale, swollen turbinates and clear rhinorrhea, are indicative of allergic rhinitis. Allergic rhinitis is characterized by an allergic response to allergens, leading to inflammation of the nasal passages and increased mucus production. Nasal polyps (choice A) typically present with nasal congestion and reduced sense of smell. Acute sinusitis (choice B) would likely present with purulent nasal discharge and facial pain/pressure. Nasal carcinoma (choice D) is unlikely in this case due to the patient's symptoms and age.
Question 5 of 5
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray for her allergies. She also reports that it does not work as well as it used to. The best response by the nurse would be:
Correct Answer: D
Rationale: The correct answer is D because over-the-counter nasal sprays, especially those containing decongestants, can lead to rebound swelling when used for an extended period. Rebound swelling occurs when the nasal passages become more congested after the effects of the medication wear off. This can result in a cycle of dependency on the nasal spray to alleviate symptoms, leading to worsening congestion over time. It is important for the nurse to educate the patient about this potential risk and suggest alternative treatment options to address her allergies effectively without causing rebound swelling. Choices A, B, and C are incorrect because: A: Incorrect, as not all over-the-counter nasal sprays carry a risk of addiction. B: Incorrect, as switching to another brand may not address the underlying issue of rebound swelling. C: Incorrect, as continuous use of the nasal spray without addressing rebound swelling can exacerbate the problem.