nclex physical and health assessment questions

Questions 46

ATI RN

ATI RN Test Bank

nclex physical and health assessment questions Questions

Question 1 of 5

A 65-year-old male has reported a crusty nodule behind the pinna. Over the past 6 months, the nodule has been bleeding intermittently and has not healed. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation would be that this:

Correct Answer: C

Rationale: The correct answer is C because the characteristics described (bleeding, not healing, ulcerated, indurated base) are indicative of a potential carcinoma, such as squamous cell carcinoma. These features raise concerns about malignancy and warrant immediate referral for further evaluation and management. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a smooth, non-ulcerated mass, Darwin's tubercle (B) is a normal anatomical variation behind the ear and not associated with bleeding or ulceration, and a tophus (D) is a deposit of uric acid crystals seen in gout and would not present in this manner.

Question 2 of 5

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the:

Correct Answer: B

Rationale: The correct answer is B: supraclavicular area. Enlarged submental lymph nodes can indicate a systemic issue. Assessing the supraclavicular area is important as it contains Virchow's node, which may indicate malignancy or metastasis. Choices A, C, and D are incorrect as they do not specifically target the area most likely to reveal significant findings related to the enlarged submental lymph nodes.

Question 3 of 5

When the retina is examined, which of the following is considered a normal finding?

Correct Answer: A

Rationale: The correct answer is A: An optic disc that is a yellow-orange colour. This is a normal finding because the optic disc typically appears yellow-orange due to the presence of nerve fibers. The yellow-orange color is due to the absence of blood vessels in this area. This is a normal anatomical characteristic of the optic disc. Option B is incorrect because blurred optic disc margins can indicate pathology such as papilledema. Option C is incorrect because the presence of pigmented crescents in the macular area can indicate a condition like myopic degeneration, not a normal finding. Option D is incorrect because the macula is normally located temporally, not nasally, to the optic disc.

Question 4 of 5

Intraocular pressure is determined by the:

Correct Answer: D

Rationale: The correct answer is D because intraocular pressure is primarily determined by the amount of aqueous humor produced and the resistance to its outflow at the angle of the anterior chamber. When there is an imbalance in the production and outflow of aqueous humor, it can lead to an increase in intraocular pressure, which can result in conditions like glaucoma. Choices A, B, and C are incorrect because they do not directly influence intraocular pressure. The thickness or bulging of the lens (A) is related to accommodation for near vision, the posterior chamber accommodating fluid (B) is not a primary factor in determining intraocular pressure, and the contraction of the ciliary body (C) affects the shape of the lens for focusing rather than intraocular pressure regulation.

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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