ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
Correct Answer: D
Rationale: The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period. Rationale: 1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth. 2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube. 3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making. 4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being. Incorrect Choices: A: "You're right, bottles make
Question 2 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 3 of 9
While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
Correct Answer: D
Rationale: The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period. Rationale: 1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth. 2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube. 3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making. 4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being. Incorrect Choices: A: "You're right, bottles make
Question 4 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 5 of 9
A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be:
Correct Answer: D
Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.
Question 6 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 7 of 9
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
Correct Answer: A
Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.
Question 8 of 9
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o'clock position in each eye. The nurse would:
Correct Answer: C
Rationale: The correct answer is C: document this as an asymmetrical light reflex. This finding indicates an asymmetry in the corneal light reflex, suggesting a possible deviation in eye alignment or muscle weakness. It is essential to document this observation for further evaluation and monitoring. Choice A is incorrect as asymmetry in the light reflex is not a normal finding. Referring for further evaluation (Choice B) would be appropriate if the asymmetry persists or is associated with other concerning symptoms. Performing the confrontation test (Choice D) is not necessary for this specific assessment and finding.
Question 9 of 9
Which of the following findings during examination would indicate Paget's disease?
Correct Answer: D
Rationale: The correct answer is D: Elongated head with heavy eyebrow ridge. Paget's disease is a bone disorder characterized by abnormal bone remodeling, leading to enlarged and deformed bones. The elongated head and heavy eyebrow ridge are typical features seen in individuals with Paget's disease due to overgrowth of bones in the skull. A: Positive MacEwen's sign - This finding is associated with congenital hip dysplasia, not Paget's disease. B: Premature closure of the sagittal suture - This is a characteristic finding in craniosynostosis, not Paget's disease. C: Headache, vertigo, tinnitus, and deafness - These symptoms are more indicative of an inner ear disorder or vestibular dysfunction, not Paget's disease.