ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 5
When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices bilateral pitting edema in the lower legs. The skin is puffy and tight but of normal colour. There is no increased redness or tenderness, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.
Question 2 of 5
A patient has come in for an examination and states,"I have this spot on my cheek here in front of my ear lobe. The spot seems to be getting bigger and is very tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
Correct Answer: B
Rationale: The correct answer is B: parotid gland. The parotid gland is located in front of the ear lobe, and swelling below the angle of the jaw is a common sign of parotid gland inflammation. The tenderness and increasing size of the spot also point towards a parotid gland issue. The other choices, such as thyroid gland (A), occipital lymph node (C), and submental lymph node (D), are incorrect as they are not typically associated with the specific symptoms described by the patient. It is essential to consider the location and function of each structure to arrive at the correct diagnosis.
Question 3 of 5
A patient has been diagnosed with"strep throat." Which complication may occur without treatment?
Correct Answer: C
Rationale: The correct answer is C: Rheumatic fever. Rheumatic fever is a possible complication of untreated strep throat due to an abnormal immune response to the streptococcal infection. This can lead to inflammation in various parts of the body, particularly the heart, joints, skin, and brain. If left untreated, rheumatic fever can cause serious long-term damage to the heart valves. The other choices are incorrect because Rubella is a viral infection causing a rash, Leukoplakia is a precancerous condition of the mouth, and Scarlet fever is a bacterial infection characterized by a red rash. These conditions are not directly associated with untreated strep throat.
Question 4 of 5
An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish blue in colour and has small vesicles. What additional information would the nurse need to know?
Correct Answer: B
Rationale: The correct answer is B: Any recent drainage from the ear. This is crucial because drainage could indicate an infection or other underlying issue causing the auricle symptoms. Hearing changes (option A) may not be directly related to the auricle findings. Recent trauma (option C) would be more evident on inspection. Prolonged cold exposure (option D) is less likely to cause the described symptoms.
Question 5 of 5
During an examination of a female patient, the nurse observes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
Correct Answer: A
Rationale: The correct answer is A: clumped. Acutely infected lymph nodes typically present as clumped due to inflammation and enlargement of multiple nodes in close proximity. This clustering is a result of the immune response to the infection. Choice B: unilateral is incorrect as lymphadenopathy in acute infection can be unilateral or bilateral. Choice C: firm but freely movable is incorrect as acutely infected lymph nodes are usually tender and may not be freely movable due to inflammation. Choice D: hard and nontender is incorrect as acutely infected lymph nodes are usually tender and may not be hard.
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