ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
What is the first priority for a client with chest pain and a history of myocardial infarction?
Correct Answer: D
Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.
Question 2 of 9
The nurse is obtaining history for a 3-month-old infant. During the interview, the mother states,"I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: A
Rationale: The correct answer is A because drooling is a common sign of teething in infants. The nurse's response should validate the mother's observation to build trust and rapport. Choice B is incorrect because teething can start as early as 3 months. Choice C is incorrect as drooling is a normal developmental milestone in infants. Choice D is incorrect as infants do not consciously control saliva production.
Question 3 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 4 of 9
During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.
Question 5 of 9
Which areas are most important to address for a client in Buck's traction?
Correct Answer: C
Rationale: Step 1: Nutrition is important for healing and energy. Step 2: Elimination is crucial for bowel and bladder function. Step 3: Comfort ensures the client's well-being. Step 4: Safety prevents complications. Step 5: ROM exercises can prevent muscle atrophy. Step 6: Transportation and isotonic exercises are not immediate priorities.
Question 6 of 9
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
Correct Answer: C
Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).
Question 7 of 9
What is the first step in the management of a client with acute renal failure?
Correct Answer: A
Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.
Question 8 of 9
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
Correct Answer: A
Rationale: The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction. Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case. Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case. Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 9 of 9
Which of the following statements about the eustachian tube is true?
Correct Answer: D
Rationale: The correct answer is D: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube connects the middle ear to the nasopharynx, allowing for pressure equalization. During activities like swallowing or yawning, the tube opens to allow air to flow in or out, maintaining equal pressure. This function is crucial for proper hearing and preventing discomfort or damage to the tympanic membrane. Choice A is incorrect as cerumen is produced by ceruminous glands in the ear canal, not the eustachian tube. Choice B is incorrect as the eustachian tube normally remains closed and opens only intermittently during specific actions. Choice C is incorrect as the eustachian tube does not connect the middle and outer ear; it connects the middle ear to the nasopharynx.