ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
Which of the following factors should a nurse consider when assessing a patient's risk for developing pressure ulcers?
Correct Answer: A
Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.
Question 2 of 9
A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:
Correct Answer: B
Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.
Question 3 of 9
During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.
Question 4 of 9
What is the most important assessment for a client with diabetes and newly diagnosed hypertension?
Correct Answer: B
Rationale: The correct answer is B: Perform a comprehensive physical exam. This is important because it helps assess the overall health status of the client, including cardiovascular risk factors that can affect both diabetes and hypertension. Monitoring blood glucose (A) is important for diabetes management but not specific to newly diagnosed hypertension. Checking for protein in the urine (C) is important for assessing kidney function in diabetes, but not the most crucial assessment for newly diagnosed hypertension. Assessing for urinary retention (D) is not directly related to managing diabetes and hypertension.
Question 5 of 9
A nurse is teaching a patient with a history of hypertension about lifestyle changes. Which of the following lifestyle modifications should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B because reducing alcohol consumption and limiting sodium intake are both crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can contribute to hypertension. By prioritizing these changes, the patient can better control their blood pressure. Choice A is incorrect because increasing sodium intake can worsen hypertension due to fluid retention. Choice C is incorrect as decreasing physical activity can lead to weight gain and worsen hypertension. Choice D is incorrect as processed foods are often high in sodium and unhealthy fats, which can negatively impact blood pressure.
Question 6 of 9
A patient's vision is recorded as 20/80 in each eye. The nurse recognizes that this finding indicates:
Correct Answer: A
Rationale: The correct answer is A: poor vision. In the 20/80 visual acuity notation, 20 represents the test distance in feet, and 80 represents the line on the eye chart that the patient can read. Therefore, a person with 20/80 vision can only see at 20 feet what a person with normal vision can see at 80 feet. This indicates poor vision as the patient's visual acuity is significantly below normal. Summary: - Choice B (acute vision) is incorrect as 20/80 vision indicates poor vision, not exceptional sharpness. - Choice C (normal vision) is incorrect as 20/80 vision is below normal range. - Choice D (presbyopia) is incorrect as presbyopia is a condition related to aging and difficulty focusing on close objects, not specifically indicated by 20/80 vision.
Question 7 of 9
The nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:
Correct Answer: C
Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.
Question 8 of 9
When examining a patient's eyes, the nurse knows that stimulation of the sympathetic branch of the autonomic nervous system:
Correct Answer: C
Rationale: The correct answer is C because stimulation of the sympathetic branch of the autonomic nervous system results in the elevation of the eyelid (ptosis) and dilation of the pupil (mydriasis). This is due to the action of the dilator pupillae muscle and the superior tarsal muscle. Pupillary constriction (choice A) is controlled by the parasympathetic branch via the sphincter pupillae muscle. Adjusting the eye for near vision (choice B) is controlled by the ciliary muscle, which is under parasympathetic control, not sympathetic. Contraction of the ciliary body (choice D) is also controlled by the parasympathetic system for accommodation of near vision, not the sympathetic system.
Question 9 of 9
Which serotonin antagonist can be used to relieve nausea and vomiting?
Correct Answer: B
Rationale: The correct answer is B: ondansetron (Zofran). Ondansetron is a selective serotonin receptor antagonist that effectively targets the serotonin receptors in the chemoreceptor trigger zone to relieve nausea and vomiting. It is commonly used in chemotherapy-induced nausea and vomiting. A: Metoclopramide is a dopamine receptor antagonist and primarily used for gastrointestinal motility disorders, not specifically for nausea relief. C: Hydroxyzine is an antihistamine with sedative properties, primarily used for anxiety and itching, not specifically for nausea relief. D: Prochlorperazine is a dopamine receptor antagonist primarily used for treating psychotic disorders, not specifically for nausea relief. In summary, ondansetron is the correct choice as it targets serotonin receptors specifically for relieving nausea and vomiting, whereas the other options focus on different mechanisms of action.