ATI RN
health assessment practice questions nursing Questions
Question 1 of 5
When using an otoscope to assess the nasal cavity, which of the following would the nurse need to do?
Correct Answer: B
Rationale: The correct answer is B. When using an otoscope to assess the nasal cavity, it is crucial to avoid touching the nasal septum with the speculum to prevent discomfort or injury to the patient. Touching the nasal septum can cause pain and potential damage. Incorrect Choices: A: Inserting the speculum at least 3 cm into the vestibule is not necessary and may cause discomfort or injury to the patient. C: Displacing the nose to the side being examined is not required and may not provide any additional benefit during the assessment. D: Keeping the speculum tip medial to avoid touching the floor of the nares is not as critical as avoiding contact with the nasal septum, which is more sensitive and can be easily injured.
Question 2 of 5
A very concerned mother is at the clinic with her infant who has a large, soft lump on the side of his head. She tells the nurse that she noticed the lump about 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is:
Correct Answer: C
Rationale: The correct answer is C: cephalhematoma. A cephalhematoma is a collection of blood between a baby's skull and the periosteum, typically occurring due to trauma during birth. In this case, the lump appeared 8 hours after birth, which aligns with the timeline for cephalhematoma development. It is soft because it consists of blood, and it can increase in size as the blood accumulates. Incorrect Choices: A: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, not a collection of blood. B: Craniosynostosis is the premature fusion of skull bones, leading to an abnormal head shape, not a collection of blood. D: Caput succedaneum is swelling of the soft tissues of a newborn's scalp due to pressure during delivery, not a collection of blood.
Question 3 of 5
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 4 of 5
Which of the following signs would the nurse expect to find on assessment of an individual with otitis externa?
Correct Answer: D
Rationale: The correct answer is D: Enlarged regional lymph nodes. In otitis externa, there may be regional lymphadenopathy due to inflammation and infection. Rhinorrhea (A) is associated with upper respiratory infections, not otitis externa. Periorbital edema (B) is seen in conditions like periorbital cellulitis. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa.
Question 5 of 5
A male patient with acquired immunodeficiency syndrome (AIDS) has come in for an examination and says,"I think that I have the mumps." The nurse would begin by examining the:
Correct Answer: B
Rationale: The correct answer is B: parotid gland. This is because mumps typically presents with swelling and tenderness of the parotid glands. The nurse should examine the parotid gland first to assess for these characteristic signs of mumps. Examining the thyroid gland (choice A) is not relevant to mumps. Cervical lymph nodes (choice C) may be swollen in various conditions but are not specific to mumps. Lastly, examining the mouth and skin for lesions (choice D) is not the initial priority when suspecting mumps.