ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles. Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.
Question 2 of 9
During the ear examination of an 80-year-old patient, which of the following would be a normal finding?
Correct Answer: C
Rationale: The correct answer is C: A thin, translucent membrane. In elderly patients, the tympanic membrane tends to become thinner and more translucent due to age-related changes. This is considered a normal finding as it is a common occurrence in older individuals. The other choices are incorrect because: A) Loss of high-tone frequency hearing is not a normal finding in an ear examination of an elderly patient, as age-related hearing loss typically affects high frequencies. B) Increased elasticity of the pinna is not a common age-related change and may indicate a different issue. D) A shiny pink tympanic membrane is not a typical finding in an elderly patient and could suggest inflammation or infection instead of a normal age-related change.
Question 3 of 9
The portion of the ear that consists of movable cartilage and skin is called the:
Correct Answer: A
Rationale: The correct answer is A: auricle. The auricle is the visible, outer portion of the ear made up of movable cartilage and skin. It serves to collect sound waves and direct them into the ear canal. The other choices are incorrect because the concha (B) is the concave cavity leading to the ear canal, the outer meatus (C) is the ear canal itself, and the mastoid process (D) is a bony protrusion behind the ear that has no role in sound collection.
Question 4 of 9
During an assessment of an 80-year-old patient, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: decreased ability to identify odors. As people age, their sense of smell tends to decline due to changes in the olfactory system. This is a common phenomenon in older adults and can impact their overall quality of life. The other choices are incorrect because hypertrophy of the gums (A) is not a typical finding in older adults, increased production of saliva (B) is not directly related to aging, and finer and less prominent nasal hair (D) is not a definitive characteristic of older age.
Question 5 of 9
A mother is concerned that her 18-month-old already has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D. At 18 months, it is expected for a child to have erupted around 16 deciduous teeth. The rationale for this answer is based on dental development milestones. By age 3, most children should have their full set of 20 primary teeth. Therefore, the nurse should inform the mother that it is normal for an 18-month-old to have around 16 teeth. Choice A is incorrect as comparing the mother's teeth at that age is irrelevant to the child's dental development. Choice B is incorrect because all 20 deciduous teeth should be present by age 3, not 4. Choice C is incorrect as having 12 teeth at 18 months is below the expected number of erupted teeth for that age.
Question 6 of 9
When examining the eye, the nurse is aware that the bulbar conjunctiva:
Correct Answer: A
Rationale: The correct answer is A: overlies the sclera. The bulbar conjunctiva is the transparent layer that covers the white part of the eye (sclera). This layer helps protect the eye and keeps it moist. It does not cover the iris and pupil (B), as that is the cornea's role. It is not visible at the inner canthus (C), which is where the lacrimal caruncle is located. Lastly, it is not a mucous membrane lining the lids (D), as that is the role of the palpebral conjunctiva. Therefore, the correct answer is A.
Question 7 of 9
When the retina is examined, which of the following is considered a normal finding?
Correct Answer: A
Rationale: The correct answer is A: An optic disc that is a yellow-orange colour. This is a normal finding because the optic disc typically appears yellow-orange due to the presence of nerve fibers. The yellow-orange color is due to the absence of blood vessels in this area. This is a normal anatomical characteristic of the optic disc. Option B is incorrect because blurred optic disc margins can indicate pathology such as papilledema. Option C is incorrect because the presence of pigmented crescents in the macular area can indicate a condition like myopic degeneration, not a normal finding. Option D is incorrect because the macula is normally located temporally, not nasally, to the optic disc.
Question 8 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 9 of 9
During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
Correct Answer: D
Rationale: The correct answer is D: the bony labyrinth. The bony labyrinth is the portion of the inner ear that includes the vestibular system responsible for balance and spatial orientation. This system detects rotational movements and contributes to the sensation of vertigo or spinning. Choice A, the cochlea, is responsible for hearing. Choice B, CN VIII (vestibulocochlear nerve), transmits auditory and balance-related information but is not the physical structure responsible for the sensation of spinning. Choice C, the organ of Corti, is located within the cochlea and is responsible for auditory transduction, not balance sensations.