ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
Correct Answer: A
Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.
Question 2 of 9
A man comes to the emergency department after he had participated in a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he"can't see well" from his left eye. The physician suspects retinal damage. Signs of retinal detachment include:
Correct Answer: B
Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area. A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially. C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field. D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.
Question 3 of 9
The nurse is assessing a 3-year-old who has been brought to the clinic for"drainage from the nose." On assessment, it is found that there is a purulent, malodorous drainage from the left naris but no drainage from the right naris. The child is afebrile and has no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.
Question 4 of 9
During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
Correct Answer: D
Rationale: The correct answer is D: the bony labyrinth. The bony labyrinth is the portion of the inner ear that includes the vestibular system responsible for balance and spatial orientation. This system detects rotational movements and contributes to the sensation of vertigo or spinning. Choice A, the cochlea, is responsible for hearing. Choice B, CN VIII (vestibulocochlear nerve), transmits auditory and balance-related information but is not the physical structure responsible for the sensation of spinning. Choice C, the organ of Corti, is located within the cochlea and is responsible for auditory transduction, not balance sensations.
Question 5 of 9
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
Correct Answer: A
Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.
Question 6 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 7 of 9
While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
Correct Answer: D
Rationale: The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period. Rationale: 1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth. 2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube. 3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making. 4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being. Incorrect Choices: A: "You're right, bottles make
Question 8 of 9
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
Correct Answer: A
Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.
Question 9 of 9
The portion of the ear that consists of movable cartilage and skin is called the:
Correct Answer: A
Rationale: The correct answer is A: auricle. The auricle is the visible, outer portion of the ear made up of movable cartilage and skin. It serves to collect sound waves and direct them into the ear canal. The other choices are incorrect because the concha (B) is the concave cavity leading to the ear canal, the outer meatus (C) is the ear canal itself, and the mastoid process (D) is a bony protrusion behind the ear that has no role in sound collection.