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 man comes to the emergency department after he had participated in a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he"can't see well" from his left eye. The physician suspects retinal damage. Signs of retinal detachment include:

Correct Answer: B

Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area. A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially. C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field. D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.

Question 2 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 3 of 5

The tissue that connects the tongue to the floor of the mouth is the:

Correct Answer: D

Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (A) is a soft tissue dangling at the back of the throat, the palate (B) is the roof of the mouth, and papillae (C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.

Question 4 of 5

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

Correct Answer: D

Rationale: The correct answer is D: increased intracranial pressure. Papilledema is swelling of the optic disc due to increased pressure in the brain. It is a sign of serious conditions like brain tumors, head trauma, or hydrocephalus. The other choices are incorrect because retinal detachment presents with visual disturbances and floaters (A), diabetic retinopathy with retinal damage due to diabetes (B), and acute-angle glaucoma with sudden eye pain and blurred vision (C). Papilledema specifically indicates increased intracranial pressure, making choice D the correct answer.

Question 5 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.

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