ATI RN
health assessment practice questions Questions
Question 1 of 9
During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.
Question 2 of 9
During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Temporal arteritis. Temporal arteritis is characterized by inflammation of the temporal arteries, leading to symptoms such as tenderness, hardness, and tortuosity. The left temporal artery being more affected than the right is a common presentation. Crepitation (choice A) refers to a crackling sound or sensation, typically associated with bone or joint abnormalities, not arterial inflammation. Mastoiditis (choice B) is an infection of the mastoid bone behind the ear, not related to temporal arteries. Bell's palsy (choice D) is a condition affecting facial nerves, not arteries.
Question 3 of 9
A mother who has brought her newborn infant for assessment tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, the baby straightens out the arm and leg on the same side and flexes the opposite arm and leg. After confirming this on examination, the nurse would tell the mother that this is:
Correct Answer: C
Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.
Question 4 of 9
During examination of a 4-year-old Aboriginal child, the nurse notices that her uvula is partially split. Which of the following statements about this condition is accurate?
Correct Answer: B
Rationale: The correct answer is B: This is a bifid uvula, which is a common occurrence in some Aboriginal groups. 1. A bifid uvula is a condition where the uvula is split or divided, which is a common variation seen in some Aboriginal populations. 2. Cleft palate is a different condition involving a gap in the roof of the mouth, not specifically related to Aboriginal people. 3. Uvular injury is not a common cause of a split uvula in children, so reporting to authorities is unnecessary. 4. Torus palatinus is a bony growth on the roof of the mouth and not related to a split uvula or specific to Aboriginal populations.
Question 5 of 9
A 32-year-old woman is at the clinic for a checkup, and she states,"I have little white bumps in my mouth." During the assessment, the nurse notes that she has a 5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. Which of the following would the nurse tell the patient?
Correct Answer: D
Rationale: The correct answer is D because Fordyce's granules are small, yellow-white or flesh-colored spots that are sebaceous glands and commonly found on the oral mucosa. They are benign and do not require treatment. In this case, the patient's description matches the characteristics of Fordyce's granules. Option A is incorrect because strep throat typically presents with other symptoms like sore throat and fever, not white bumps in the mouth. Option B is incorrect as there is no indication of a serious lesion based on the description given. Option C is incorrect as leukoplakia is a condition associated with chronic irritation, not Fordyce's granules.
Question 6 of 9
During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.
Question 7 of 9
When assessing the tongue of an adult, an abnormal finding would be:
Correct Answer: A
Rationale: The correct answer is A because a smooth, glossy dorsal surface of the tongue is abnormal in adults and may indicate glossitis or nutritional deficiencies. B is incorrect as a thin white coating is normal. Raised papillae (choice C) may indicate transient lingual papillitis but are not typically abnormal. Visible venous patterns (choice D) are normal on the ventral surface.
Question 8 of 9
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
Correct Answer: C
Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).
Question 9 of 9
Tests have shown that a patient has sensorineural hearing loss. During the assessment, it would be important for the nurse to:
Correct Answer: B
Rationale: The correct answer is B: assess for middle ear infection as a possible cause. Sensorineural hearing loss is usually caused by damage to the inner ear or the nerve pathway to the brain. Middle ear infection can sometimes lead to conductive hearing loss, but it's important to rule out this possibility during assessment. Speaking loudly (A) is not effective for sensorineural hearing loss. Asking about medications (C) may be relevant but not as crucial as assessing for a possible cause. Looking for external ear obstruction (D) is more relevant for conductive hearing loss, not sensorineural.