ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
Correct Answer: A
Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.
Question 2 of 9
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: increased intracranial pressure. Papilledema is swelling of the optic disc due to increased pressure in the brain. It is a sign of serious conditions like brain tumors, head trauma, or hydrocephalus. The other choices are incorrect because retinal detachment presents with visual disturbances and floaters (A), diabetic retinopathy with retinal damage due to diabetes (B), and acute-angle glaucoma with sudden eye pain and blurred vision (C). Papilledema specifically indicates increased intracranial pressure, making choice D the correct answer.
Question 3 of 9
A patient's medical record describes a lesion that is confluent in nature. On examination, the nurse would expect to find:
Correct Answer: A
Rationale: The correct answer is A: lesions that run together. Confluent lesions refer to merging or blending of individual lesions to form a larger lesion. This indicates a continuous area of involvement on the skin. Choices B, C, and D do not accurately describe confluent lesions as they refer to different patterns of lesion distribution such as annular, linear, or grouped. The key to identifying confluent lesions is the concept of merging or running together, which is best represented by choice A.
Question 4 of 9
Which of the following is the best way to palpate the lymph nodes in the neck?
Correct Answer: D
Rationale: The correct answer is D because using the index and middle fingers to palpate with gentle pressure in a rotating pattern allows for a thorough examination of the lymph nodes without causing discomfort or injury. This method helps to assess the size, shape, consistency, and tenderness of the nodes accurately. It also enables the examiner to detect any abnormalities such as enlargement or tenderness. A is incorrect as using strong pressure can be painful and lead to inaccurate assessment. B is incorrect as strong pressure can be harmful and may not provide the necessary sensitivity to detect abnormalities. C is incorrect as pinching each node can be uncomfortable and may not allow for a systematic examination of the lymph nodes.
Question 5 of 9
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: D
Rationale: The correct answer is D. The nurse would want to ask about the number of ear infections the baby has had since birth because aspirin exposure during pregnancy is associated with an increased risk of developing Reye's syndrome, which can lead to recurrent ear infections. This question helps assess the baby's risk for complications related to aspirin exposure. Choices A, B, and C are incorrect as they are not directly related to the potential complications associated with aspirin exposure during pregnancy.
Question 6 of 9
The nurse is testing the hearing of a 78-year-old man. Which of the following age-related hearing changes should the nurse keep in mind? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Age-related hearing loss begins in the mid-40s. This is because presbycusis, or age-related hearing loss, typically starts around the mid-40s due to natural aging processes affecting the inner ear. Choice B is incorrect as the progression of hearing loss can vary, being gradual for some individuals but not necessarily slow for everyone. Choice C is incorrect as high-frequency tone loss, not low-frequency, is commonly associated with aging. Choice D is incorrect as difficulty hearing consonants is more related to specific types of hearing loss, not solely age-related changes.
Question 7 of 9
A father brings his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been occurring at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant?
Correct Answer: A
Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.
Question 8 of 9
A 65-year-old male has reported a crusty nodule behind the pinna. Over the past 6 months, the nodule has been bleeding intermittently and has not healed. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation would be that this:
Correct Answer: C
Rationale: The correct answer is C because the characteristics described (bleeding, not healing, ulcerated, indurated base) are indicative of a potential carcinoma, such as squamous cell carcinoma. These features raise concerns about malignancy and warrant immediate referral for further evaluation and management. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a smooth, non-ulcerated mass, Darwin's tubercle (B) is a normal anatomical variation behind the ear and not associated with bleeding or ulceration, and a tophus (D) is a deposit of uric acid crystals seen in gout and would not present in this manner.
Question 9 of 9
A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be:
Correct Answer: D
Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.