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 92-year-old patient has had a stroke, and the right side of his face is drooping. What else would the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. In a stroke patient with right-sided facial drooping, dysphagia is highly likely due to the involvement of the facial nerve, leading to difficulty swallowing. Epistaxis (A) is nosebleeds, agenesis (B) is the absence of a body part, and xerostomia (D) is dry mouth, which are not directly related to facial drooping in stroke patients. Dysphagia is a common complication post-stroke due to impaired muscle control, making it the most likely concern for the nurse to suspect in this case.
Question 3 of 9
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 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 5 of 9
When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.
Correct Answer: C
Rationale: The correct answer is C, parotid and submandibular glands. The parotid and submandibular glands are the two pairs of salivary glands that are accessible for examination in the face. The parotid gland is located near the ear, while the submandibular gland is located under the jaw. The other choices are incorrect because: A: Occipital and submental glands are not salivary glands accessible for examination in the face. B: Parotid gland is correct, but jugulodigastric gland is not a salivary gland. D: Submandibular gland is correct, but occipital gland is not a salivary gland.
Question 6 of 9
A patient says that she has recently noticed a lump in the front of her neck below her"Adam's apple" that seems to be getting bigger. During the assessment, the finding that reassures the nurse that this may not be a cancerous thyroid nodule is that the lump (nodule):
Correct Answer: B
Rationale: The correct answer is B: the lump is mobile and not hard. A cancerous thyroid nodule is typically fixed and hard, whereas a noncancerous nodule is more likely to be mobile and soft. This characteristic suggests it may be a benign condition such as a thyroid cyst rather than a malignant tumor. The other choices are incorrect because A: tenderness does not necessarily indicate benignity or malignancy, C: disappearance when smiling is more related to a salivary gland issue, and D: hardness and fixation are more indicative of a potentially cancerous nodule.
Question 7 of 9
During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small, compared with an enlarged cranium. On further examination, the nurse also notes dilated scalp veins and downcast, or"setting sun," eyes. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.
Question 8 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 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.