ATI RN
health assessment practice questions Questions
Question 1 of 9
The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.
Question 2 of 9
What should be the nurse's first action when a client develops a fever after surgery?
Correct Answer: A
Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.
Question 3 of 9
The nurse is teaching parents of a newborn about feeding their infant. Which instruction should the nurse include?
Correct Answer: A
Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.
Question 4 of 9
A nurse is teaching a patient with heart failure about managing their condition. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.
Question 5 of 9
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 6 of 9
A nurse is assessing a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.
Question 7 of 9
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 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
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.