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
The nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:
Correct Answer: C
Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.
Question 3 of 9
Which of the following assessment findings is most consistent with clubbing of the fingernails?
Correct Answer: D
Rationale: Clubbing of the fingernails is characterized by an increased angle between the nail base and the nail plate (usually 180 degrees or greater) and a spongy texture at the nail base. This is due to underlying tissue changes associated with conditions like lung disease. Choice D is correct as it accurately describes the characteristic findings of clubbing. Choices A, B, and C do not align with clubbing features. Choice A describes tenderness and firmness, not sponginess and increased angle. Choice B mentions a convex profile and ridges, which are not specific to clubbing. Choice C includes an angle of 150 degrees, which is less than the typical angle seen in clubbing.
Question 4 of 9
During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Temporal arteritis. Temporal arteritis is characterized by inflammation of the temporal arteries, leading to symptoms such as tenderness, hardness, and tortuosity. The left temporal artery being more affected than the right is a common presentation. Crepitation (choice A) refers to a crackling sound or sensation, typically associated with bone or joint abnormalities, not arterial inflammation. Mastoiditis (choice B) is an infection of the mastoid bone behind the ear, not related to temporal arteries. Bell's palsy (choice D) is a condition affecting facial nerves, not arteries.
Question 5 of 9
Which of the following statements about the eustachian tube is true?
Correct Answer: D
Rationale: The correct answer is D: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube connects the middle ear to the nasopharynx, allowing for pressure equalization. During activities like swallowing or yawning, the tube opens to allow air to flow in or out, maintaining equal pressure. This function is crucial for proper hearing and preventing discomfort or damage to the tympanic membrane. Choice A is incorrect as cerumen is produced by ceruminous glands in the ear canal, not the eustachian tube. Choice B is incorrect as the eustachian tube normally remains closed and opens only intermittently during specific actions. Choice C is incorrect as the eustachian tube does not connect the middle and outer ear; it connects the middle ear to the nasopharynx.
Question 6 of 9
During an assessment, a patient says that she was diagnosed with open-angle glaucoma 2 years ago. There are various types of glaucoma, such as open-angle glaucoma and closed-angle glaucoma. Which of the following are characteristics of open-angle glaucoma? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: It is the most common type of glaucoma. Open-angle glaucoma is indeed the most common type, accounting for about 90% of all glaucoma cases. In open-angle glaucoma, the drainage angle of the eye remains open, but the trabecular meshwork becomes blocked over time. This leads to increased intraocular pressure, which can damage the optic nerve and result in vision loss. A, C, and D are incorrect: A: The symptoms mentioned (sensitivity to light, nausea, halos around lights) are more commonly associated with acute angle-closure glaucoma, not open-angle glaucoma. C: Immediate treatment is not necessarily needed for open-angle glaucoma as it progresses slowly, and treatment can vary based on the severity of the condition. D: Vision loss in open-angle glaucoma typically starts with the loss of peripheral vision, not central vision.
Question 7 of 9
During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.
Question 8 of 9
The papule on the nose of a 52-year-old woman has rounded, pearly borders and a central red ulcer. She tells the nurse that it has been present for several months and is slowly growing larger. Which of the following conditions does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Basal cell carcinoma. The clinical presentation of a papule with rounded, pearly borders, central red ulcer, slow growth, and location on the nose is highly indicative of basal cell carcinoma. Basal cell carcinoma commonly presents with these characteristics and is the most common type of skin cancer. It is locally invasive but rarely metastasizes. A: Acne is a common skin condition characterized by comedones, papules, and pustules, not typically presenting with the described features. C: Malignant melanoma usually presents as an asymmetric, irregularly bordered, multicolored lesion with rapid growth and potential for metastasis. D: Squamous cell carcinoma typically presents as a scaly, crusted lesion with potential for metastasis, not showing the described features.
Question 9 of 9
The mother of a 2-year-old is concerned about tympanostomy tubes that are going to be inserted in her son's ears. Which of the following would the nurse include in the teaching plan?
Correct Answer: D
Rationale: Rationale for Correct Answer D: Tympanostomy tubes are inserted into the eardrum to help drain fluid from the middle ear, relieve pressure, and prevent infections. This is important in children who have recurrent ear infections or fluid buildup. By allowing drainage, the tubes help improve hearing and reduce the risk of complications. Summary of Incorrect Choices: A) Incorrect - Tympanostomy tubes are placed in the middle ear, not the inner ear. B) Incorrect - Tympanostomy tubes are used for conductive hearing loss, not sensorineural loss. C) Incorrect - Tympanostomy tubes are not permanently inserted and are usually removed after a period of time once they are no longer needed.