ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (A) is a soft tissue dangling at the back of the throat, the palate (B) is the roof of the mouth, and papillae (C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.
Question 2 of 9
The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
Correct Answer: A
Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.
Question 3 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 4 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 5 of 9
A man comes to the emergency department after he had participated in a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he"can't see well" from his left eye. The physician suspects retinal damage. Signs of retinal detachment include:
Correct Answer: B
Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area. A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially. C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field. D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.
Question 6 of 9
Which of the following best describes the test to assess the function of cranial nerve (CN) X?
Correct Answer: D
Rationale: The correct answer is D because cranial nerve X, also known as the vagus nerve, controls the movement of the soft palate and uvula. Asking the patient to say "ahhh" assesses the function of CN X as the soft palate and uvula should elevate symmetrically. A: Observing the patient's ability to articulate specific words does not specifically test CN X function. B: Assessing movement of the hard palate and uvula with the gag reflex primarily tests CN IX (glossopharyngeal nerve). C: Having the patient stick out the tongue and observing for tremors or pulling to one side primarily tests CN XII (hypoglossal nerve).
Question 7 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.
Question 8 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 9 of 9
A patient with a middle ear infection asks the nurse,"What does the middle ear do?" The nurse says that the function of the middle ear is to:
Correct Answer: C
Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.