Questions 9

ATI RN

ATI RN Test Bank

nclex practice questions 2023 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 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 3 of 5

During an examination of a female patient, the nurse observes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:

Correct Answer: A

Rationale: The correct answer is A: clumped. Acutely infected lymph nodes typically present as clumped due to inflammation and enlargement of multiple nodes in close proximity. This clustering is a result of the immune response to the infection. Choice B: unilateral is incorrect as lymphadenopathy in acute infection can be unilateral or bilateral. Choice C: firm but freely movable is incorrect as acutely infected lymph nodes are usually tender and may not be freely movable due to inflammation. Choice D: hard and nontender is incorrect as acutely infected lymph nodes are usually tender and may not be hard.

Question 4 of 5

A patient has been diagnosed with"strep throat." Which complication may occur without treatment?

Correct Answer: C

Rationale: The correct answer is C: Rheumatic fever. Rheumatic fever is a possible complication of untreated strep throat due to an abnormal immune response to the streptococcal infection. This can lead to inflammation in various parts of the body, particularly the heart, joints, skin, and brain. If left untreated, rheumatic fever can cause serious long-term damage to the heart valves. The other choices are incorrect because Rubella is a viral infection causing a rash, Leukoplakia is a precancerous condition of the mouth, and Scarlet fever is a bacterial infection characterized by a red rash. These conditions are not directly associated with untreated strep throat.

Question 5 of 5

During the oral assessment of a 30-year-old patient of African descent, the nurse notes bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bluish lips indicate cyanosis, a sign of inadequate oxygen supply. 2. Dark line along gingival margin suggests lead poisoning. 3. The nurse should assess for other signs of inadequate oxygen supply to determine the severity and underlying cause. 4. This finding is not normal and requires further evaluation to prevent complications. Summary: A: Checking hemoglobin for anemia is not the immediate priority when cyanosis and lead poisoning are suspected. C: Assuming this is a normal finding can lead to overlooking a potentially serious condition. D: Carbon monoxide exposure could be a consideration, but assessing for overall oxygen supply is more crucial in this scenario.

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