health assessment practice questions

Questions 45

ATI RN

ATI RN Test Bank

health assessment practice questions Questions

Question 1 of 5

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. Which of the following about this technique is true?

Correct Answer: D

Rationale: The correct answer is D because asking the patient to hold his nose and swallow causes the eustachian tube to open, equalizing pressure in the middle ear. This action will cause the eardrum to bulge slightly outward, making landmarks more visible. Choice A is incorrect as age alone does not preclude the use of this technique. Choice B is incorrect because this technique is not primarily used for assessing otitis media. Choice C is incorrect as it is not specific to upper respiratory infections.

Question 2 of 5

In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Red glow in pupils indicates a normal reflection off the inner retina known as the red reflex. 2. The red reflex helps to visualize the internal structures of the eye, including the retina. 3. This finding is expected during an ophthalmoscopic examination. 4. No abnormality is suggested by the presence of a red glow in the pupils. Summary of Other Choices: A: Incorrect. Red glow does not indicate an opacity in the lens or cornea. B: Incorrect. Checking the light source is unnecessary as red glow is a normal finding. D: Incorrect. Referral is not needed as red reflex is a normal part of an ophthalmoscopic exam.

Question 3 of 5

During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.

Question 4 of 5

The papule on the nose of a 52-year-old woman has rounded, pearly borders and a central red ulcer. She tells the nurse that it has been present for several months and is slowly growing larger. Which of the following conditions does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Basal cell carcinoma. The clinical presentation of a papule with rounded, pearly borders, central red ulcer, slow growth, and location on the nose is highly indicative of basal cell carcinoma. Basal cell carcinoma commonly presents with these characteristics and is the most common type of skin cancer. It is locally invasive but rarely metastasizes. A: Acne is a common skin condition characterized by comedones, papules, and pustules, not typically presenting with the described features. C: Malignant melanoma usually presents as an asymmetric, irregularly bordered, multicolored lesion with rapid growth and potential for metastasis. D: Squamous cell carcinoma typically presents as a scaly, crusted lesion with potential for metastasis, not showing the described features.

Question 5 of 5

When assessing the tongue of an adult, an abnormal finding would be:

Correct Answer: A

Rationale: The correct answer is A because a smooth, glossy dorsal surface of the tongue is abnormal in adults and may indicate glossitis or nutritional deficiencies. B is incorrect as a thin white coating is normal. Raised papillae (choice C) may indicate transient lingual papillitis but are not typically abnormal. Visible venous patterns (choice D) are normal on the ventral surface.

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