ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
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 5
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (A) is a soft tissue dangling at the back of the throat, the palate (B) is the roof of the mouth, and papillae (C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.
Question 3 of 5
The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
Correct Answer: A
Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.
Question 4 of 5
A patient presents with excruciating pain on one side of his head, especially around his eye, forehead, and cheek, that occurs once or twice each day and lasts about 30 minutes to 2 hours. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: cluster headaches. Cluster headaches are characterized by excruciating pain on one side of the head, often around the eye, forehead, and cheek. They occur once or twice each day and last for a relatively short duration of 30 minutes to 2 hours. This pattern of symptoms aligns with the typical presentation of cluster headaches. Incorrect Choices: A: Hypertension is unlikely to present with such specific unilateral head pain patterns and timing. C: Tension headaches typically present with more diffuse, mild to moderate pain and are not typically associated with eye, forehead, or cheek pain. D: Migraine headaches usually last longer than 2 hours and are commonly associated with other symptoms such as nausea, vomiting, and sensitivity to light and sound.
Question 5 of 5
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.
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