ATI RN
health assessment practice questions nursing Questions
Question 1 of 9
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Correct Answer: B
Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.
Question 2 of 9
When examining children with Down's syndrome (trisomy 21), the nurse looks for the possible presence of:
Correct Answer: C
Rationale: Step 1: Down's syndrome is associated with characteristic physical features. Step 2: One common physical feature is a protruding tongue due to a small oral cavity. Step 3: This is known as macroglossia and is seen in individuals with Down's syndrome. Step 4: Therefore, the nurse looks for a protruding thin tongue in children with Down's syndrome. Summary: A is incorrect because ear dysplasia is not a common feature. B is incorrect as a long, thin neck is not a typical characteristic. D is incorrect because a narrow and raised nasal bridge is not a key feature of Down's syndrome.
Question 3 of 9
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say:
Correct Answer: C
Rationale: The correct answer is C because purpura is characterized by the presence of confluent and extensive patches of petechiae and ecchymoses. Petechiae are small, pinpoint hemorrhages less than 2mm in size, and ecchymoses are larger bruises. This presentation is indicative of a more severe underlying condition, such as a bleeding disorder or vasculitis. Choice A is incorrect as it describes spider veins or telangiectasias, not purpura. Choice B describes a birthmark, not purpura. Choice D is incorrect as it describes petechiae, not purpura, which involves larger areas of bleeding.
Question 4 of 9
The physician has diagnosed a tracheal shift in a patient. The nurse is aware that this means that the patient's trachea is:
Correct Answer: D
Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.
Question 5 of 9
Which of the following would the nurse expect to find when examining the eyes of a patient of African descent?
Correct Answer: B
Rationale: The correct answer is B: A dark retinal background. This is because individuals of African descent typically have a higher concentration of melanin in their eyes, resulting in a darker retinal background. This can affect the appearance of the fundus during eye examinations. Incorrect choices: A: Increased night vision - Night vision is not directly influenced by melanin levels in the eyes and is more related to the function of rods and cones in the retina. C: Increased photosensitivity - Melanin provides some protection against UV light, so individuals with darker retinas may have lower photosensitivity. D: Narrowed palpebral fissures - Palpebral fissures refer to the opening between the eyelids and are not typically influenced by melanin levels in the eyes.
Question 6 of 9
The nurse is assessing a patient's eyes for the accommodation response and would expect to see:
Correct Answer: D
Rationale: The correct answer is D: convergence of the axes of the eyes. During the accommodation response, the eyes converge to focus on a near object. This is necessary to maintain clear vision when looking at close objects. Dilation of the pupils (A) is not part of the accommodation response. A consensual light reflex (B) refers to both pupils constricting simultaneously in response to light, not specific to accommodation. Conjugate movement of the eyes (C) refers to both eyes moving together in the same direction, which is not the primary action during accommodation.
Question 7 of 9
A mother brings her newborn in for an assessment and asks,"Is there something wrong with my baby? His head seems so big." Which of the following does the nurse know about the relative proportions of the head and trunk in the newborn?
Correct Answer: A
Rationale: The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns. Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.
Question 8 of 9
Which of the following statements about otoscopic examination of a newborn would be true?
Correct Answer: C
Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.
Question 9 of 9
Which of the following statements about the outer layer of the eye is true?
Correct Answer: C
Rationale: The correct answer is C because the trigeminal (CN V) and the trochlear (CN IV) nerves are indeed stimulated when the outer surface of the eye is stimulated. The trigeminal nerve is responsible for the sensation of touch in the face and controls the muscles involved in chewing. The trochlear nerve controls the superior oblique muscle of the eye, which helps with downward and inward eye movements. Therefore, when the outer layer of the eye is touched or stimulated, these nerves are activated to convey the sensation to the brain. Choices A, B, and D are incorrect: A: The outer layer of the eye is not particularly sensitive to touch compared to other areas like the cornea or conjunctiva. B: The outer layer of the eye is not darkly pigmented; the pigmented layer is actually the uvea inside the eye. D: The visual receptive layer of the eye, known as the retina, is located deeper within the eye, not