ATI RN
health assessment practice questions Questions
Question 1 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 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
Which of the following factors should a nurse consider when assessing a patient's risk for developing pressure ulcers?
Correct Answer: A
Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.
Question 4 of 9
A nurse is assessing a patient with a history of smoking. The patient reports a persistent cough that has worsened over the past few months. The nurse would be most concerned about the possibility of:
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.
Question 5 of 9
Which electrolyte is lost with intestinal suctioning in a client with an ileus?
Correct Answer: D
Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.
Question 6 of 9
Which technique is most effective for assessing the patient's abdominal organ size?
Correct Answer: B
Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.
Question 7 of 9
Which nursing measure is most appropriate to meet the expected outcome of positive body image in a client with Kawasaki disease?
Correct Answer: C
Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.
Question 8 of 9
An 85-year-old female patient is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse provide?
Correct Answer: C
Rationale: The correct answer is C because as individuals age, there is a natural decrease in skin elasticity, subcutaneous fat, and moisture content in the skin. These factors contribute to the bones becoming more noticeable in the face. Choice A is incorrect because diets low in protein and high in carbohydrates do not directly cause enlargement of facial bones. Choice B is incorrect as the use of a specific moisturizer does not directly impact the visibility of facial bones. Choice D is incorrect because facial skin actually loses elasticity with age, leading to less taut skin and more prominent bones.
Question 9 of 9
What is the primary goal for a client with newly diagnosed diabetes?
Correct Answer: B
Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.