ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
Which of the following statements about air conduction is true?
Correct Answer: D
Rationale: The correct answer is D because a loss of air conduction, known as conductive hearing loss, refers to a problem conducting sound waves through the outer or middle ear. This type of hearing loss can be caused by issues such as earwax buildup, fluid in the middle ear, or problems with the ear canal or eardrum. Choices A, B, and C are incorrect because air conduction is not the most efficient pathway for hearing (choice A), it is not caused by vibrations of bones in the skull (choice B), and the pitch of sound is determined by the frequency, not the amplitude (choice C). Conductive hearing loss specifically relates to the transmission of sound through the outer and middle ear structures, making choice D the correct statement.
Question 2 of 9
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Correct Answer: B
Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.
Question 3 of 9
The physician has diagnosed a tracheal shift in a patient. The nurse is aware that this means that the patient's trachea is:
Correct Answer: D
Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.
Question 4 of 9
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notes the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:
Correct Answer: B
Rationale: The correct answer is B: hyphema. Hyphema is the presence of blood in the anterior chamber of the eye, which can occur due to trauma like being hit with a baseball bat. This indicates bleeding inside the eye, specifically in the space between the cornea and iris. Hypopyon (A) is the accumulation of white blood cells in the anterior chamber. Corneal abrasion (C) is a scratch on the cornea, not related to blood in the anterior chamber. Iritis (D) is inflammation of the iris, which does not necessarily involve blood in the anterior chamber.
Question 5 of 9
A patient is unable to read the 20/100 line on the Snellen chart. The nurse would:
Correct Answer: A
Rationale: The correct answer is A. Referring the patient to an ophthalmologist or optometrist is the appropriate action because the patient's inability to read the 20/100 line on the Snellen chart suggests significant visual impairment that requires professional evaluation. Options B and C are incorrect as they do not address the underlying cause of the vision issue. Option B focuses on a different method of assessment and does not provide a solution for the patient's visual acuity problem. Option C assumes the patient's vision issue can be corrected by reading glasses, which may not be the case for a 20/100 visual acuity. Option D is also incorrect as it only adjusts the testing distance and does not address the need for a comprehensive evaluation by an eye care specialist.
Question 6 of 9
To assess colour vision in a male child, the nurse would:
Correct Answer: C
Rationale: The correct answer is C because testing for color vision once between the ages of 4 and 8 is appropriate to assess any potential color vision deficiencies. This age range is crucial as color vision development is mostly completed by the age of 8. Annual checks (A) are not necessary unless there are specific concerns. Asking the child to identify clothing color (B) may not be a reliable indicator of color vision deficiency. No information is provided for option D.
Question 7 of 9
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 8 of 9
The nurse is testing a patient's visual accommodation, which refers to:
Correct Answer: A
Rationale: Visual accommodation refers to the ability of the eye to adjust focus when shifting gaze between objects at different distances. The correct answer is A, pupillary constriction when looking at a near object, as this is a key component of visual accommodation. When looking at a near object, the eye needs to adjust its focus by constricting the pupil to allow more depth of field and clearer vision. This process helps in bringing near objects into focus. Choices B, C, and D are incorrect: B: Pupillary dilation when looking at a far object is not related to visual accommodation, as the pupil dilates in low light conditions to allow more light to enter the eye. C: Changes in peripheral vision in response to light is not related to visual accommodation, as peripheral vision refers to the ability to see objects outside the direct line of sight. D: Involuntary blinking in the presence of bright light is a protective reflex to shield the eyes from excessive light and is not directly related to visual
Question 9 of 9
A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know how to prevent it. The nurse instructs her to:
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Rubbing alcohol or 2% acetic acid eardrops help to maintain the pH balance in the ear canal, making it less conducive to bacterial growth. 2. These eardrops also help to dry out excess moisture, reducing the risk of otitis externa. 3. By using these eardrops after every swim, the student can prevent the recurrence of otitis externa. Summary of other choices: A: Using a cotton-tipped swab can push wax deeper into the ear canal, increasing the risk of infection. C: Irrigating the ears can introduce water into the ear canal, potentially worsening the condition. D: Mineral oil and hydrogen peroxide can be harsh on the delicate skin of the ear canal, causing irritation.