Questions 9

ATI RN

ATI RN Test Bank

nclex practice questions 2023 health assessment Questions

Question 1 of 5

While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes. The nodes are approximately 5 cm in size, round, mobile, and nontender. The nurse suspects that this:

Correct Answer: B

Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.

Question 2 of 5

When assessing inflammation in a dark-skinned person, the nurse may need to:

Correct Answer: C

Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.

Question 3 of 5

During a well-baby checkup, the mother expresses concern that her 2-month-old infant is not able to hold her head up when she is pulled to a sitting position. Which of the following responses by the nurse is appropriate?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Head control typically develops around 4 months, so it is normal for a 2-month-old to lack this skill. 2. Reassuring the mother that her baby is within the normal developmental range is important for reducing parental anxiety. 3. Avoiding overly alarming responses helps maintain trust and open communication with the parent. Summary: - Choice B is incorrect as it does not address the mother's concern and may come across as dismissive. - Choice C is incorrect as it may unnecessarily worry the mother and lead to undue stress. - Choice D is incorrect as it introduces a serious and unlikely scenario without evidence at this stage of development.

Question 4 of 5

A 2-week-old infant can fixate on an object but not follow a light or bright toy. The nurse would:

Correct Answer: A

Rationale: The correct answer is A because fixating on an object at 2 weeks is within the expected developmental range. Infants typically develop the ability to follow objects later on. Choice B is incorrect as absence of following light doesn't indicate blindness. Choice C is unnecessary and premature. Choice D is incorrect as the ability to follow objects typically develops around 6-8 weeks.

Question 5 of 5

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

Correct Answer: D

Rationale: The presence of black and white dots on the tympanic membrane and ear canal wall during an otoscopic examination suggests a yeast or fungal infection. This is because yeast or fungal infections commonly present as white or black dots in the ear canal. Malignancy would typically manifest as abnormal growths or masses, not dots. Viral infections usually do not present as specific dots on the tympanic membrane. Blood in the middle ear would appear as red or pinkish fluid behind the eardrum, not as black and white dots. Therefore, the correct answer is D: Yeast or fungal infection.

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