ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
The nurse is unable to suction the nares of a newborn immediately following delivery. The attempt to pass a catheter through both nasal cavities has met with no success. What would be the nurse's best action in this situation?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Immediate intervention is crucial as the newborn needs clear airways for breathing. 2. Inability to suction the nares can lead to respiratory distress and compromise the infant's oxygenation. 3. Waiting or attempting again may delay necessary actions, risking the baby's health. 4. Physician's assistance may be needed, but recognizing the urgency is the nurse's responsibility to ensure timely care. Summary of Incorrect Choices: A. Attempting to suction again with a bulb syringe may not resolve the issue and delay necessary intervention. B. Waiting for the infant to stop crying is not ideal as it may prolong the risk of respiratory distress. D. While physician assistance may be necessary, immediate recognition of the critical situation is the nurse's primary responsibility.
Question 2 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 3 of 9
A mother brings her newborn in for an assessment and asks,"Is there something wrong with my baby? His head seems so big." Which of the following does the nurse know about the relative proportions of the head and trunk in the newborn?
Correct Answer: A
Rationale: The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns. Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.
Question 4 of 9
A patient is unable to read the 20/100 line on the Snellen chart. The nurse would:
Correct Answer: A
Rationale: The correct answer is A. Referring the patient to an ophthalmologist or optometrist is the appropriate action because the patient's inability to read the 20/100 line on the Snellen chart suggests significant visual impairment that requires professional evaluation. Options B and C are incorrect as they do not address the underlying cause of the vision issue. Option B focuses on a different method of assessment and does not provide a solution for the patient's visual acuity problem. Option C assumes the patient's vision issue can be corrected by reading glasses, which may not be the case for a 20/100 visual acuity. Option D is also incorrect as it only adjusts the testing distance and does not address the need for a comprehensive evaluation by an eye care specialist.
Question 5 of 9
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Correct Answer: B
Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.
Question 6 of 9
To assess colour vision in a male child, the nurse would:
Correct Answer: C
Rationale: The correct answer is C because testing for color vision once between the ages of 4 and 8 is appropriate to assess any potential color vision deficiencies. This age range is crucial as color vision development is mostly completed by the age of 8. Annual checks (A) are not necessary unless there are specific concerns. Asking the child to identify clothing color (B) may not be a reliable indicator of color vision deficiency. No information is provided for option D.
Question 7 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 8 of 9
The physician has diagnosed a tracheal shift in a patient. The nurse is aware that this means that the patient's trachea is:
Correct Answer: D
Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.
Question 9 of 9
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say:
Correct Answer: C
Rationale: The correct answer is C because purpura is characterized by the presence of confluent and extensive patches of petechiae and ecchymoses. Petechiae are small, pinpoint hemorrhages less than 2mm in size, and ecchymoses are larger bruises. This presentation is indicative of a more severe underlying condition, such as a bleeding disorder or vasculitis. Choice A is incorrect as it describes spider veins or telangiectasias, not purpura. Choice B describes a birthmark, not purpura. Choice D is incorrect as it describes petechiae, not purpura, which involves larger areas of bleeding.