ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 5
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of the following indicates the significance of this in relation to the infant's hearing?
Correct Answer: B
Rationale: The correct answer is B because rubella can indeed damage the organ of Corti in the fetus, which is responsible for hearing. During the first trimester, when the hearing structures are forming, any damage to the organ of Corti can result in impaired hearing for the infant. Choice A is incorrect because rubella can impact the fetus, including the organs responsible for hearing. Choice C is incorrect because rubella can be harmful to the fetus at any stage of pregnancy, not just the second trimester. Choice D is incorrect because CN VIII (the vestibulocochlear nerve) is not directly affected by rubella, rather it is the organ of Corti that is damaged.
Question 2 of 5
A patient has had a"terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior. Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.
Question 3 of 5
The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.
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
A semiconscious woman is brought to the emergency department after being found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red colour. The nurse suspects that this colouring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloring in a semiconscious woman found on the floor in her kitchen indicates carbon monoxide poisoning. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red coloration. Polycythemia would result in a purplish-red color, carotenemia in a yellow-orange hue, and uremia in a pale or yellowish complexion. Therefore, the correct answer is B, as it aligns with the clinical presentation and pathophysiology of carbon monoxide poisoning.
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