ATI RN
nclex physical and health assessment questions Questions
Question 1 of 9
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 2 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.
Question 3 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 4 of 9
While performing a voice test to assess hearing in a patient, which of the following would the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.
Question 5 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 6 of 9
Which of the following is a risk factor for ear infections in young children?
Correct Answer: D
Rationale: The correct answer is D: Second-hand cigarette smoke. Exposure to second-hand smoke can irritate and inflame the lining of the Eustachian tube, making young children more susceptible to ear infections. This is supported by research showing a clear link between exposure to cigarette smoke and increased rates of ear infections in children. Family history (A) may contribute to genetic predisposition but is not a direct risk factor. Air conditioning (B) does not directly cause ear infections. Excessive cerumen (C) can lead to blockages but is not a primary risk factor for infections.
Question 7 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 8 of 9
Jaundice is manifested by a yellow skin colour, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice?
Correct Answer: B
Rationale: Step 1: Jaundice is characterized by a yellow skin color due to elevated bilirubin levels. Step 2: Yellow color extending up to the iris indicates systemic jaundice, involving the whole body. Step 3: Yellow patches throughout the sclera (Choice A) may not indicate systemic jaundice. Step 4: Skin appearing yellow under low light (Choice C) may not be specific to jaundice. Step 5: Yellow deposits on palms and soles (Choice D) are not typical signs of jaundice. Therefore, Choice B is correct as it reflects systemic jaundice, while the other choices do not fully align with the manifestation of true jaundice.
Question 9 of 9
The temporomandibular joint is just below the temporal artery and anterior to the:
Correct Answer: D
Rationale: The correct answer is D: mandible. The temporomandibular joint is located just below the temporal artery and it connects the mandible (lower jaw) to the temporal bone. This joint allows for movement of the jaw during actions like chewing and speaking. Choices A, B, and C are incorrect because the temporomandibular joint is not located near the hyoid bone (A), the vagus nerve (B), or the tragus of the ear (C). These structures are not directly associated with the temporomandibular joint's anatomical location and function.