ATI RN
health assessment practice questions Questions
Question 1 of 9
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 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 3 of 9
A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. Which of the following about this technique is true?
Correct Answer: D
Rationale: The correct answer is D because asking the patient to hold his nose and swallow causes the eustachian tube to open, equalizing pressure in the middle ear. This action will cause the eardrum to bulge slightly outward, making landmarks more visible. Choice A is incorrect as age alone does not preclude the use of this technique. Choice B is incorrect because this technique is not primarily used for assessing otitis media. Choice C is incorrect as it is not specific to upper respiratory infections.
Question 4 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 5 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 6 of 9
A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?
Correct Answer: D
Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.
Question 7 of 9
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.
Question 8 of 9
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 9 of 9
The nurse is performing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, grey, and swollen. What would be the most appropriate question to ask the patient?
Correct Answer: A
Rationale: The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms. B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction. C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction. D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.