ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.
Question 2 of 9
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 3 of 9
The nurse has discovered decreased skin turgor in a patient. In which of the following would this be an expected finding?
Correct Answer: C
Rationale: The correct answer is C: In an individual who is severely dehydrated. Decreased skin turgor is a clinical sign of dehydration, indicating loss of skin elasticity due to fluid loss. Severe dehydration leads to decreased skin turgor as the skin loses its ability to recoil when pinched. In cases of severe obesity (choice A), skin turgor is usually normal or increased due to excess adipose tissue. During childhood growth spurts (choice B), skin turgor is typically unaffected. Connective tissue disorders like scleroderma (choice D) can lead to changes in skin texture and appearance, but not necessarily decreased skin turgor.
Question 4 of 9
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
Correct Answer: A
Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.
Question 5 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.
Question 6 of 9
A woman is at the clinic for a checkup and says,"My eyes have gotten puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:
Correct Answer: C
Rationale: The correct answer is C: myxedema. This is a classic presentation of hypothyroidism, specifically myxedema, characterized by puffy eyes, coarse hair, and dry skin. The thyroid hormone deficiency leads to decreased metabolic activity, causing these symptoms. Cachexia (A) is severe muscle wasting seen in conditions like cancer. Cretinism (B) is congenital hypothyroidism leading to mental retardation. Scleroderma (D) is a connective tissue disorder causing skin thickening, not typically associated with these symptoms.
Question 7 of 9
The nurse notices that the patient has bluish white, red-based spots in her mouth that are elevated about 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description of a red-purple, maculopapular, blotchy rash behind the ears and on the face is characteristic of a condition called Koplik spots, which are associated with measles. Measles is a highly contagious viral infection that presents with symptoms such as cough, runny nose, high fever, and a widespread rash. The presence of Koplik spots in the mouth is a classic early sign of measles. Choices A, B, and C are incorrect because they do not align with the specific description of the patient's mouth spots or other expected signs of measles. It's essential for the nurse to recognize the unique features of Koplik spots to promptly identify and manage measles infection.
Question 8 of 9
The nurse is testing the hearing of a 78-year-old man. Which of the following age-related hearing changes should the nurse keep in mind? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Age-related hearing loss begins in the mid-40s. This is because presbycusis, or age-related hearing loss, typically starts around the mid-40s due to natural aging processes affecting the inner ear. Choice B is incorrect as the progression of hearing loss can vary, being gradual for some individuals but not necessarily slow for everyone. Choice C is incorrect as high-frequency tone loss, not low-frequency, is commonly associated with aging. Choice D is incorrect as difficulty hearing consonants is more related to specific types of hearing loss, not solely age-related changes.
Question 9 of 9
The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?
Correct Answer: B
Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.