Questions 9

ATI RN

ATI RN Test Bank

nclex physical and health assessment questions Questions

Question 1 of 5

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 5

Which of the following assessment findings would the nurse be most concerned about?

Correct Answer: D

Rationale: The correct answer is D, an ulceration with rolled edges on the side of the tongue, as it could indicate a possible malignancy such as oral cancer. The presence of rolled edges is concerning for malignancy due to the irregularity in shape and potential for rapid growth. This finding should be promptly investigated to rule out cancer. A: A painful vesicle inside the cheek for 2 days is likely a benign condition such as a canker sore. B: The presence of moist, nontender Stenson's ducts is a normal finding in the mouth. C: Stippled gingival margins that adhere snugly to the teeth could indicate a healthy gum tissue attachment. In summary, the other choices are less concerning as they are either benign or normal variations, while the presence of an ulceration with rolled edges raises significant suspicion for malignancy.

Question 3 of 5

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 5

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 5 of 5

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.

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