ATI RN
health assessment practice questions Questions
Question 1 of 5
The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?
Correct Answer: A
Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.
Question 2 of 5
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
Correct Answer: A
Rationale: The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction. Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case. Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case. Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 3 of 5
The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure?
Correct Answer: C
Rationale: The correct answer is C: Tilt the child's head slightly toward the examiner. This position straightens the ear canal, facilitating visualization. Pulling the pinna down (A) can cause discomfort and obstruct the view. Pulling the pinna up and back (B) is incorrect for a child under 3 years old as it straightens the ear canal in adults. Having the child touch his chin to his chest (D) is unnecessary and may lead to improper examination positioning.
Question 4 of 5
During ear examination, the patient reports that he is hears a buzzing sound that is"driving me crazy!" The nurse recognizes that this symptom is:
Correct Answer: C
Rationale: The correct answer is C: tinnitus. Tinnitus is the perception of sound without an external source, often described as ringing, buzzing, or hissing. In this case, the patient reporting a buzzing sound aligns with tinnitus. Vertigo (A) is a sensation of spinning or dizziness, not a sound perception. Pruritus (B) is itching, not a sound perception. Cholesteatoma (D) is a benign growth in the middle ear, not specifically related to sound perception. Therefore, tinnitus is the most appropriate choice based on the patient's symptom of hearing a buzzing sound.
Question 5 of 5
Which of the following about a newborn infant is true?
Correct Answer: C
Rationale: The correct answer is C because the frontal sinuses are indeed fairly well developed at birth. This is true as the frontal sinuses start developing around the age of 7-8 years but are present in a rudimentary form at birth. This is because the frontal bone grows rapidly in the first few years of life, allowing for the development of the frontal sinuses. Choice A is incorrect because the sphenoid sinuses are not at full size at birth; they continue to develop throughout childhood. Choice B is incorrect as the maxillary sinuses reach full size around the teenage years, not after puberty. Choice D is incorrect as the frontal sinuses are also present at birth, along with the maxillary and ethmoid sinuses.