ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
Which serotonin antagonist can be used to relieve nausea and vomiting?
Correct Answer: B
Rationale: The correct answer is B: ondansetron (Zofran). Ondansetron is a selective serotonin receptor antagonist that effectively targets the serotonin receptors in the chemoreceptor trigger zone to relieve nausea and vomiting. It is commonly used in chemotherapy-induced nausea and vomiting. A: Metoclopramide is a dopamine receptor antagonist and primarily used for gastrointestinal motility disorders, not specifically for nausea relief. C: Hydroxyzine is an antihistamine with sedative properties, primarily used for anxiety and itching, not specifically for nausea relief. D: Prochlorperazine is a dopamine receptor antagonist primarily used for treating psychotic disorders, not specifically for nausea relief. In summary, ondansetron is the correct choice as it targets serotonin receptors specifically for relieving nausea and vomiting, whereas the other options focus on different mechanisms of action.
Question 2 of 9
A mother who has brought her newborn infant for assessment tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, the baby straightens out the arm and leg on the same side and flexes the opposite arm and leg. After confirming this on examination, the nurse would tell the mother that this is:
Correct Answer: C
Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.
Question 3 of 9
A mother brings her 4-month-old to the clinic with concerns about a small padlike growth on the mid- upper lip that has been present since the baby was 1 month old. The infant has no health problems. On physical examination, the nurse notes a 5-cm, fleshy, elevated area on the mid-upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother?
Correct Answer: D
Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.
Question 4 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.
Question 5 of 9
What is the priority nursing action for a client who is experiencing severe chest pain?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. The priority nursing action for a client experiencing severe chest pain is to administer nitroglycerin to help dilate the blood vessels and improve blood flow to the heart, reducing chest pain. This action helps to address the immediate issue of chest pain and potential heart damage. Administering morphine (B) may be considered if chest pain persists despite nitroglycerin. Administering oxygen (C) can also be helpful but is not the initial priority. Monitoring blood pressure (D) is important but not the most urgent action in this scenario.
Question 6 of 9
While taking a detailed history, what should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Functional status. Including functional status in the history is essential as it provides information about the client's ability to perform activities of daily living. This information is crucial for assessing the client's overall health and well-being. Functional status helps the nurse understand the impact of health issues on the client's daily life and helps in planning appropriate care interventions. B: Data focusing on the client complaint is too narrow and may not provide a comprehensive understanding of the client's health status. C: A focused assessment of the client complaint may overlook other important aspects of the client's health that could impact their overall well-being. D: Family history for the past three generations is not typically included in a detailed history-taking process and may not be directly relevant to the client's current health status.
Question 7 of 9
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
Correct Answer: A
Rationale: The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction. Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case. Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case. Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 8 of 9
What should the nurse do when a client develops severe shortness of breath after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.
Question 9 of 9
The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?
Correct Answer: A
Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.