ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 9
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 9
When examining an older adult, which of the following findings would the nurse recognize as related to the aging process?
Correct Answer: A
Rationale: The correct answer is A: Teeth that appear shorter. As people age, teeth naturally wear down and may appear shorter due to years of use. This is a normal part of the aging process. B: A smoother tongue is not a typical age-related change. C: Beefy red buccal mucosa may be indicative of an underlying health issue, not solely related to aging. D: A painless lump on the tongue could be a sign of a more serious condition and should be investigated further.
Question 3 of 9
A patient has had a"terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior. Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.
Question 4 of 9
Which of the following cranial nerves (CNs) is responsible for conducting nerve impulses to the brain from the organ of Corti?
Correct Answer: C
Rationale: The correct answer is C: CN VIII. The vestibulocochlear nerve (CN VIII) is responsible for conducting nerve impulses from the organ of Corti in the inner ear to the brain. This nerve specifically carries auditory information to the brainstem and auditory cortex for processing. Choice A (CN I) is incorrect as it is the olfactory nerve responsible for smell. Choice B (CN III) is incorrect as it is the oculomotor nerve responsible for eye movement. Choice D (CN XI) is incorrect as it is the accessory nerve responsible for neck and shoulder movements.
Question 5 of 9
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?
Correct Answer: C
Rationale: The correct answer is C: Erythematous scaly patch with sharp margins in the sacral area. In patients with AIDS, this presentation is most likely indicative of a common opportunistic infection called tinea corporis. This fungal infection often presents as erythematous scaly patches with well-defined borders. The location in the sacral area is also common due to the warm and moist environment. Choice A, tinea capitis, is a fungal infection of the scalp and is not typically associated with AIDS. Choice B describes a presentation more indicative of a condition like seborrheic dermatitis rather than an AIDS-related skin manifestation. Choice D describes a presentation more typical of tinea corporis, which is not commonly seen in the axilla region in patients with AIDS.
Question 6 of 9
Which of the following physiological changes is responsible for presbyopia?
Correct Answer: B
Rationale: The correct answer is B, loss of lens elasticity. Presbyopia is the age-related loss of near vision due to the lens becoming less flexible, making it harder to focus on close objects. With aging, the lens loses its ability to change shape, affecting near vision. Other choices are incorrect because presbyopia is primarily related to changes in the lens, not the cornea (A), adaptation to darkness (C), or distance vision abilities (D).
Question 7 of 9
While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes. The nodes are approximately 5 cm in size, round, mobile, and nontender. The nurse suspects that this:
Correct Answer: B
Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.
Question 8 of 9
The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.
Question 9 of 9
The muscles in the neck that are innervated by CN XI are the:
Correct Answer: A
Rationale: The correct answer is A: sternomastoid and trapezius. CN XI, also known as the spinal accessory nerve, innervates the sternomastoid and trapezius muscles. The sternomastoid muscle is responsible for neck rotation and flexion, while the trapezius muscle is responsible for shoulder movement and stability. The other choices are incorrect because the omohyoid and sternomandibular muscles are not innervated by CN XI. The spinal accessory nerve does not innervate the omohyoid muscle, and the sternomandibular muscle is not a recognized muscle in the neck. Therefore, choices B, C, and D are incorrect.