ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: D
Rationale: The correct answer is D. The nurse would want to ask about the number of ear infections the baby has had since birth because aspirin exposure during pregnancy is associated with an increased risk of developing Reye's syndrome, which can lead to recurrent ear infections. This question helps assess the baby's risk for complications related to aspirin exposure. Choices A, B, and C are incorrect as they are not directly related to the potential complications associated with aspirin exposure during pregnancy.
Question 2 of 9
The nurse is assessing a 3-year-old who has been brought to the clinic for"drainage from the nose." On assessment, it is found that there is a purulent, malodorous drainage from the left naris but no drainage from the right naris. The child is afebrile and has no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.
Question 3 of 9
A father brings his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been occurring at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant?
Correct Answer: A
Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.
Question 4 of 9
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: increased intracranial pressure. Papilledema is swelling of the optic disc due to increased pressure in the brain. It is a sign of serious conditions like brain tumors, head trauma, or hydrocephalus. The other choices are incorrect because retinal detachment presents with visual disturbances and floaters (A), diabetic retinopathy with retinal damage due to diabetes (B), and acute-angle glaucoma with sudden eye pain and blurred vision (C). Papilledema specifically indicates increased intracranial pressure, making choice D the correct answer.
Question 5 of 9
The portion of the ear that consists of movable cartilage and skin is called the:
Correct Answer: A
Rationale: The correct answer is A: auricle. The auricle is the visible, outer portion of the ear made up of movable cartilage and skin. It serves to collect sound waves and direct them into the ear canal. The other choices are incorrect because the concha (B) is the concave cavity leading to the ear canal, the outer meatus (C) is the ear canal itself, and the mastoid process (D) is a bony protrusion behind the ear that has no role in sound collection.
Question 6 of 9
A man comes to the emergency department after he had participated in a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he"can't see well" from his left eye. The physician suspects retinal damage. Signs of retinal detachment include:
Correct Answer: B
Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area. A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially. C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field. D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.
Question 7 of 9
The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?
Correct Answer: B
Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.
Question 8 of 9
A woman is at the clinic for a checkup and says,"My eyes have gotten puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:
Correct Answer: C
Rationale: The correct answer is C: myxedema. This is a classic presentation of hypothyroidism, specifically myxedema, characterized by puffy eyes, coarse hair, and dry skin. The thyroid hormone deficiency leads to decreased metabolic activity, causing these symptoms. Cachexia (A) is severe muscle wasting seen in conditions like cancer. Cretinism (B) is congenital hypothyroidism leading to mental retardation. Scleroderma (D) is a connective tissue disorder causing skin thickening, not typically associated with these symptoms.
Question 9 of 9
A patient with a middle ear infection asks the nurse,"What does the middle ear do?" The nurse says that the function of the middle ear is to:
Correct Answer: C
Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.