ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
What would be a normal finding when assessing the lacrimal apparatus during an eye examination?
Correct Answer: A
Rationale: The correct answer is A: The presence of tears along the inner canthus. This is a normal finding during an eye examination as tears are produced by the lacrimal gland and drain into the nasolacrimal duct, which exits at the inner canthus. This indicates proper tear production and drainage. Incorrect choices: B: A blocked nasolacrimal duct in a newborn infant - This would present as excessive tearing and discharge. C: A slight swelling over the upper lid and along the bony orbit if the patient has a cold - This could indicate inflammation due to infection. D: The absence of drainage from the puncta when the inner orbital rim is pressed - This would suggest an issue with the lacrimal drainage system.
Question 2 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 3 of 9
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 4 of 9
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale: Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms. Therefore, the correct answer is C: maxillary sinusitis.
Question 5 of 9
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During assessment, the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:
Correct Answer: B
Rationale: The correct answer is B: candidiasis. Candidiasis is a fungal infection caused by Candida albicans, commonly seen in immunocompromised individuals like cancer patients post-chemotherapy. The raw, red, and bleeding areas indicate mucosal irritation, while the white, cheesy coating represents fungal overgrowth. Carcinoma (choice A) refers to cancerous growths, which typically present differently. Leukoplakia (choice C) is a precancerous lesion characterized by white patches, not raw areas with bleeding. Koplik's spots (choice D) are small, white spots seen in the mouth in measles, not indicative of the described findings.
Question 6 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 7 of 9
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o'clock position in each eye. The nurse would:
Correct Answer: C
Rationale: The correct answer is C: document this as an asymmetrical light reflex. This finding indicates an asymmetry in the corneal light reflex, suggesting a possible deviation in eye alignment or muscle weakness. It is essential to document this observation for further evaluation and monitoring. Choice A is incorrect as asymmetry in the light reflex is not a normal finding. Referring for further evaluation (Choice B) would be appropriate if the asymmetry persists or is associated with other concerning symptoms. Performing the confrontation test (Choice D) is not necessary for this specific assessment and finding.
Question 8 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 9 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.