ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
When examining the nares of a 45-year-old patient who complains of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notes the following: pale, swollen turbinates and clear rhinorrhea. Which of the following is most likely the cause?
Correct Answer: C
Rationale: The correct answer is C: Allergic rhinitis. The patient's symptoms of rhinorrhea, itching, and sneezing, along with pale, swollen turbinates and clear rhinorrhea, are indicative of allergic rhinitis. Allergic rhinitis is characterized by an allergic response to allergens, leading to inflammation of the nasal passages and increased mucus production. Nasal polyps (choice A) typically present with nasal congestion and reduced sense of smell. Acute sinusitis (choice B) would likely present with purulent nasal discharge and facial pain/pressure. Nasal carcinoma (choice D) is unlikely in this case due to the patient's symptoms and age.
Question 2 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 3 of 9
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. Which of the following would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections. Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong. Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections. Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.
Question 4 of 9
During the assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is indicative of:
Correct Answer: A
Rationale: The dry mucosa and deep fissures in the tongue indicate dehydration in the patient. Dehydration causes decreased saliva production, leading to dry mouth and tongue fissures. This is a common symptom of dehydration. The lack of moisture in the oral cavity can result in these physical signs. The other choices are incorrect because irritation by gastric juices typically presents with other symptoms, a normal oral condition would not show these specific findings, and side effects of nausea medication would not directly cause dry mucosa and deep fissures in the tongue. Therefore, the correct answer is A: dehydration.
Question 5 of 9
The nurse is taking history from a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the concern of a possible perforated eardrum by inquiring about the relationship between ear pain and discharge. This is crucial in assessing the severity of the condition. Choice A is incorrect as it focuses on subjective symptoms not specific to a perforated eardrum. Choice B is irrelevant as it doesn't pertain to the immediate concern. Choice C is also incorrect as it doesn't target the current issue of a potential perforated eardrum. Asking about ear pain and discharge helps determine the likelihood of a perforated eardrum and guides further assessment and care.
Question 6 of 9
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:
Correct Answer: A
Rationale: The correct answer is A: she may have macular degeneration. Macular degeneration is characterized by loss of central vision while peripheral vision remains intact. In this case, the woman's difficulty with tasks that require central vision, such as reading and recognizing faces, points towards macular degeneration. The other choices are incorrect because: B: Her symptoms indicate a specific vision problem, not just age-related changes. C: Cataracts typically cause blurred vision, not loss of central vision. D: Glaucoma typically affects peripheral vision first before progressing to central vision loss.
Question 7 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 8 of 9
While performing a mouth assessment on a patient, the nurse notices a 1-cm ulceration that is crusted and has an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to obtain?
Correct Answer: B
Rationale: The correct answer is B: When the patient first noticed the lesion. This information is crucial for determining the duration of the ulceration, aiding in diagnosing potential causes like trauma or infections. Nutritional status (Choice A) may not be directly related to the specific lesion. Whether the patient has had a recent cold (Choice C) is less relevant unless there are other symptoms present. Exposure to sick animals (Choice D) is not pertinent to the mouth ulceration. Therefore, obtaining information on when the patient first noticed the lesion is the most important for proper assessment and treatment planning.
Question 9 of 9
The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Bloody or clear watery drainage can indicate a basal skull fracture. 2. Basal skull fractures can cause cerebrospinal fluid leakage, leading to clear watery drainage. 3. Blood in the ear canal can suggest a temporal bone fracture. 4. Assessing for drainage helps identify potential serious head injuries. Summary: A. Incorrect. Purulent drainage indicates infection, not related to head injuries. C. Incorrect. Increased cerumen is not the priority in assessing head injuries. D. Incorrect. Foreign bodies in the canal are not the primary concern in this scenario.