ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
The nurse is performing middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and visible landmarks. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.
Question 2 of 9
The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
Correct Answer: B
Rationale: The correct answer is B: not palpable. In healthy adults, most lymph nodes are not palpable as they are typically small and not easily detectable through touch. This indicates normal lymphatic function and absence of significant inflammation or infection. Choices A, C, and D describe characteristics of abnormal lymph nodes, such as being shotty, large/firm/fixed, or rubbery/discrete/mobile, respectively, which are indicative of pathological conditions like infection, malignancy, or inflammation. Therefore, the absence of palpable lymph nodes in a healthy individual is the expected norm.
Question 3 of 9
When examining children with Down's syndrome (trisomy 21), the nurse looks for the possible presence of:
Correct Answer: C
Rationale: Step 1: Down's syndrome is associated with characteristic physical features. Step 2: One common physical feature is a protruding tongue due to a small oral cavity. Step 3: This is known as macroglossia and is seen in individuals with Down's syndrome. Step 4: Therefore, the nurse looks for a protruding thin tongue in children with Down's syndrome. Summary: A is incorrect because ear dysplasia is not a common feature. B is incorrect as a long, thin neck is not a typical characteristic. D is incorrect because a narrow and raised nasal bridge is not a key feature of Down's syndrome.
Question 4 of 9
The nurse is performing middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and visible landmarks. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.
Question 5 of 9
The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Bloody or clear watery drainage can indicate a basal skull fracture. 2. Basal skull fractures can cause cerebrospinal fluid leakage, leading to clear watery drainage. 3. Blood in the ear canal can suggest a temporal bone fracture. 4. Assessing for drainage helps identify potential serious head injuries. Summary: A. Incorrect. Purulent drainage indicates infection, not related to head injuries. C. Incorrect. Increased cerumen is not the priority in assessing head injuries. D. Incorrect. Foreign bodies in the canal are not the primary concern in this scenario.
Question 6 of 9
Which of the following statements about otoscopic examination of a newborn would be true?
Correct Answer: C
Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.
Question 7 of 9
The nurse is taking history from a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the concern of a possible perforated eardrum by inquiring about the relationship between ear pain and discharge. This is crucial in assessing the severity of the condition. Choice A is incorrect as it focuses on subjective symptoms not specific to a perforated eardrum. Choice B is irrelevant as it doesn't pertain to the immediate concern. Choice C is also incorrect as it doesn't target the current issue of a potential perforated eardrum. Asking about ear pain and discharge helps determine the likelihood of a perforated eardrum and guides further assessment and care.
Question 8 of 9
A 40-year-old woman reports a change in mole size, accompanied by colour changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
Correct Answer: B
Rationale: The correct answer is B because the patient's symptoms (change in mole size, color changes, itching, burning, bleeding) are concerning for melanoma, a type of skin cancer. Given her history of blistering sunburns, early evaluation and referral are crucial for timely intervention. Option A is incorrect as it delays necessary evaluation. Option C is irrelevant as the symptoms suggest a serious condition, not environmental irritants. Option D is incorrect as compound nevi typically do not present with the described symptoms and are not common in this age group.
Question 9 of 9
The nurse is assessing a patient's eyes for the accommodation response and would expect to see:
Correct Answer: D
Rationale: The correct answer is D: convergence of the axes of the eyes. During the accommodation response, the eyes converge to focus on a near object. This is necessary to maintain clear vision when looking at close objects. Dilation of the pupils (A) is not part of the accommodation response. A consensual light reflex (B) refers to both pupils constricting simultaneously in response to light, not specific to accommodation. Conjugate movement of the eyes (C) refers to both eyes moving together in the same direction, which is not the primary action during accommodation.