ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
Which of the following best describes the test to assess the function of cranial nerve (CN) X?
Correct Answer: D
Rationale: The correct answer is D because cranial nerve X, also known as the vagus nerve, controls the movement of the soft palate and uvula. Asking the patient to say "ahhh" assesses the function of CN X as the soft palate and uvula should elevate symmetrically. A: Observing the patient's ability to articulate specific words does not specifically test CN X function. B: Assessing movement of the hard palate and uvula with the gag reflex primarily tests CN IX (glossopharyngeal nerve). C: Having the patient stick out the tongue and observing for tremors or pulling to one side primarily tests CN XII (hypoglossal nerve).
Question 2 of 5
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 3 of 5
A mother is concerned that her 18-month-old already has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D. At 18 months, it is expected for a child to have erupted around 16 deciduous teeth. The rationale for this answer is based on dental development milestones. By age 3, most children should have their full set of 20 primary teeth. Therefore, the nurse should inform the mother that it is normal for an 18-month-old to have around 16 teeth. Choice A is incorrect as comparing the mother's teeth at that age is irrelevant to the child's dental development. Choice B is incorrect because all 20 deciduous teeth should be present by age 3, not 4. Choice C is incorrect as having 12 teeth at 18 months is below the expected number of erupted teeth for that age.
Question 4 of 5
Which of the following assessment findings would the nurse be most concerned about?
Correct Answer: D
Rationale: The correct answer is D, an ulceration with rolled edges on the side of the tongue, as it could indicate a possible malignancy such as oral cancer. The presence of rolled edges is concerning for malignancy due to the irregularity in shape and potential for rapid growth. This finding should be promptly investigated to rule out cancer. A: A painful vesicle inside the cheek for 2 days is likely a benign condition such as a canker sore. B: The presence of moist, nontender Stenson's ducts is a normal finding in the mouth. C: Stippled gingival margins that adhere snugly to the teeth could indicate a healthy gum tissue attachment. In summary, the other choices are less concerning as they are either benign or normal variations, while the presence of an ulceration with rolled edges raises significant suspicion for malignancy.
Question 5 of 5
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.