ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
The nurse has discovered decreased skin turgor in a patient. In which of the following would this be an expected finding?
Correct Answer: C
Rationale: The correct answer is C: In an individual who is severely dehydrated. Decreased skin turgor is a clinical sign of dehydration, indicating loss of skin elasticity due to fluid loss. Severe dehydration leads to decreased skin turgor as the skin loses its ability to recoil when pinched. In cases of severe obesity (choice A), skin turgor is usually normal or increased due to excess adipose tissue. During childhood growth spurts (choice B), skin turgor is typically unaffected. Connective tissue disorders like scleroderma (choice D) can lead to changes in skin texture and appearance, but not necessarily decreased skin turgor.
Question 2 of 5
A father brings his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been occurring at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant?
Correct Answer: A
Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.
Question 3 of 5
A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be:
Correct Answer: D
Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.
Question 4 of 5
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _____ and starts the examination by:
Correct Answer: B
Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice D) is not relevant to testing the function of CN XI.
Question 5 of 5
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the:
Correct Answer: B
Rationale: The correct answer is B: supraclavicular area. Enlarged submental lymph nodes can indicate a systemic issue. Assessing the supraclavicular area is important as it contains Virchow's node, which may indicate malignancy or metastasis. Choices A, C, and D are incorrect as they do not specifically target the area most likely to reveal significant findings related to the enlarged submental lymph nodes.