ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 5
Which of the following is an expected normal finding in the diagnostic positions test?
Correct Answer: D
Rationale: The correct answer is D: A slight amount of lid lag when moving the eyes from a superior position to an inferior position. In the diagnostic positions test, when the eyes move from an extreme superior position to an inferior position, a slight amount of lid lag is expected due to the normal anatomical structure and mechanics of the eye muscles and eyelids. This lag is a normal finding and not indicative of any underlying pathology. Rationale: A: Convergence of vision in both eyes is not a normal finding in the diagnostic positions test as convergence refers to the inward movement of both eyes towards each other to maintain single binocular vision. B: Parallel movement of both eyes is not a specific finding in the diagnostic positions test. The test is designed to assess the movement of the eyes in different directions. C: Nystagmus in extreme superior gaze is not a normal finding and indicates an abnormality in eye movement coordination, not an expected finding in the diagnostic positions test.
Question 2 of 5
A 2-week-old infant can fixate on an object but not follow a light or bright toy. The nurse would:
Correct Answer: A
Rationale: The correct answer is A because fixating on an object at 2 weeks is within the expected developmental range. Infants typically develop the ability to follow objects later on. Choice B is incorrect as absence of following light doesn't indicate blindness. Choice C is unnecessary and premature. Choice D is incorrect as the ability to follow objects typically develops around 6-8 weeks.
Question 3 of 5
The nurse notes the presence of periorbital edema when performing eye assessment on a 70-year-old patient. The nurse will:
Correct Answer: B
Rationale: The correct answer is B: suspect that the patient has hyperthyroidism. Periorbital edema is a common sign of hyperthyroidism due to the accumulation of fluid in the tissues around the eyes. By suspecting hyperthyroidism, the nurse can further assess for other associated symptoms and recommend appropriate diagnostic tests. Choice A (check for the presence of exophthalmos) is incorrect because exophthalmos refers to bulging eyes, which may be present in hyperthyroidism but is not directly related to periorbital edema. Choice C (ask the patient if he or she has a history of heart failure) is incorrect as periorbital edema is not typically associated with heart failure, which usually presents with generalized edema. Choice D (assess for blepharitis) is incorrect because while blepharitis can cause eyelid inflammation, it is not typically associated with periorbital edema seen in hyper
Question 4 of 5
A patient complains of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is:
Correct Answer: B
Rationale: The correct answer is B: a hordeolum (stye). A hordeolum is a localized infection in the eyelid, typically caused by bacterial infection of the oil glands. In this case, the presence of a painful pustule at the lid margin, along with redness and swelling, is characteristic of a hordeolum. The pain on touch is also indicative of an infection. Choice A, a chalazion, is an inflammatory lesion caused by a blocked oil gland, but it is usually painless and not typically associated with redness or tenderness. Choice C, dacryocystitis, is an infection of the lacrimal sac, which presents with different symptoms such as tenderness over the inner corner of the eye and tearing. Choice D, blepharitis, is inflammation of the eyelid margins, but it does not typically present with a painful pustule at the lid margin.
Question 5 of 5
During an ophthalmoscopic examination of a patient, the examiner notes areas of exudate that look like"cotton wool" or fluffy grey-white cumulus clouds. Which of the possible problems below does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Diabetes. The presence of "cotton wool" or fluffy grey-white cumulus clouds on ophthalmoscopic examination indicates retinal nerve fiber layer infarcts due to microvascular damage, which is a common finding in diabetic retinopathy. This occurs due to ischemia and subsequent axonal swelling. In diabetes, hyperglycemia can lead to damage in the blood vessels supplying the retina, resulting in microaneurysms, hemorrhages, exudates, and ultimately vision loss if left untreated. Summary of other choices: B: Hyperthyroidism - This condition primarily affects the thyroid gland and does not directly cause the characteristic retinal findings described. C: Glaucoma - Glaucoma is a condition characterized by increased intraocular pressure and optic nerve damage, which does not typically present with the specific retinal findings mentioned. D: Hypotension - Low blood pressure may lead to retinal artery occlusion or ischemic optic neuropathy,