ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. Which of the following would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections. Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong. Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections. Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.
Question 2 of 9
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say:
Correct Answer: C
Rationale: The correct answer is C because purpura is characterized by the presence of confluent and extensive patches of petechiae and ecchymoses. Petechiae are small, pinpoint hemorrhages less than 2mm in size, and ecchymoses are larger bruises. This presentation is indicative of a more severe underlying condition, such as a bleeding disorder or vasculitis. Choice A is incorrect as it describes spider veins or telangiectasias, not purpura. Choice B describes a birthmark, not purpura. Choice D is incorrect as it describes petechiae, not purpura, which involves larger areas of bleeding.
Question 3 of 9
Which of the following signs would the nurse expect to find on assessment of an individual with otitis externa?
Correct Answer: D
Rationale: The correct answer is D: Enlarged regional lymph nodes. In otitis externa, there may be regional lymphadenopathy due to inflammation and infection. Rhinorrhea (A) is associated with upper respiratory infections, not otitis externa. Periorbital edema (B) is seen in conditions like periorbital cellulitis. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa.
Question 4 of 9
Which of the following would the nurse expect to find when examining the eyes of a patient of African descent?
Correct Answer: B
Rationale: The correct answer is B: A dark retinal background. This is because individuals of African descent typically have a higher concentration of melanin in their eyes, resulting in a darker retinal background. This can affect the appearance of the fundus during eye examinations. Incorrect choices: A: Increased night vision - Night vision is not directly influenced by melanin levels in the eyes and is more related to the function of rods and cones in the retina. C: Increased photosensitivity - Melanin provides some protection against UV light, so individuals with darker retinas may have lower photosensitivity. D: Narrowed palpebral fissures - Palpebral fissures refer to the opening between the eyelids and are not typically influenced by melanin levels in the eyes.
Question 5 of 9
While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?
Correct Answer: B
Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.
Question 6 of 9
During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management. A: Continuing the examination is not appropriate as the bruit should prompt further investigation. B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue. C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.
Question 7 of 9
The nurse is testing a patient's visual accommodation, which refers to:
Correct Answer: A
Rationale: Visual accommodation refers to the ability of the eye to adjust focus when shifting gaze between objects at different distances. The correct answer is A, pupillary constriction when looking at a near object, as this is a key component of visual accommodation. When looking at a near object, the eye needs to adjust its focus by constricting the pupil to allow more depth of field and clearer vision. This process helps in bringing near objects into focus. Choices B, C, and D are incorrect: B: Pupillary dilation when looking at a far object is not related to visual accommodation, as the pupil dilates in low light conditions to allow more light to enter the eye. C: Changes in peripheral vision in response to light is not related to visual accommodation, as peripheral vision refers to the ability to see objects outside the direct line of sight. D: Involuntary blinking in the presence of bright light is a protective reflex to shield the eyes from excessive light and is not directly related to visual
Question 8 of 9
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red and circular with central clearing, and is located across his midriff and behind his knees. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: Lyme disease. The presentation of a red circular rash with central clearing, known as erythema migrans, following a hiking trip in the summer is highly indicative of Lyme disease. The specific distribution of the rash across the midriff and behind the knees aligns with typical areas where the rash appears in Lyme disease cases. This rash is a hallmark sign of early Lyme disease caused by the bacterium Borrelia burgdorferi transmitted through the bite of an infected tick. Other answer choices are incorrect because rubeola presents with a different rash pattern, an allergy to mosquito bites would not typically present in this manner, and Rocky Mountain spotted fever typically presents with a different rash appearance and distribution.
Question 9 of 9
A very concerned mother is at the clinic with her infant who has a large, soft lump on the side of his head. She tells the nurse that she noticed the lump about 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is:
Correct Answer: C
Rationale: The correct answer is C: cephalhematoma. A cephalhematoma is a collection of blood between a baby's skull and the periosteum, typically occurring due to trauma during birth. In this case, the lump appeared 8 hours after birth, which aligns with the timeline for cephalhematoma development. It is soft because it consists of blood, and it can increase in size as the blood accumulates. Incorrect Choices: A: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, not a collection of blood. B: Craniosynostosis is the premature fusion of skull bones, leading to an abnormal head shape, not a collection of blood. D: Caput succedaneum is swelling of the soft tissues of a newborn's scalp due to pressure during delivery, not a collection of blood.