nclex practice questions 2023 health assessment

Questions 46

ATI RN

ATI RN Test Bank

nclex practice questions 2023 health assessment Questions

Question 1 of 5

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish blue in colour and has small vesicles. What additional information would the nurse need to know?

Correct Answer: B

Rationale: The correct answer is B: Any recent drainage from the ear. This is crucial because drainage could indicate an infection or other underlying issue causing the auricle symptoms. Hearing changes (option A) may not be directly related to the auricle findings. Recent trauma (option C) would be more evident on inspection. Prolonged cold exposure (option D) is less likely to cause the described symptoms.

Question 2 of 5

When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices bilateral pitting edema in the lower legs. The skin is puffy and tight but of normal colour. There is no increased redness or tenderness, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema?

Correct Answer: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.

Question 3 of 5

The salivary gland that is located in the cheek in front of the ear is the:

Correct Answer: A

Rationale: The correct answer is A: parotid gland. This gland is located in the cheek in front of the ear. It is the largest salivary gland in the human body. The parotid gland secretes saliva into the mouth through Stenson's duct. The other choices are incorrect because Stenson's gland does not exist, the sublingual gland is located under the tongue, and the submandibular gland is located under the mandible. Therefore, the parotid gland is the only gland that fits the description given in the question.

Question 4 of 5

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that:

Correct Answer: B

Rationale: The correct answer is B: the patient can read at 6.1 m (20 ft) what a person with normal vision can read at 9.1 m (30 ft). This is because the Snellen notation 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet. This ratio signifies the patient's visual acuity compared to a person with normal vision. The other choices are incorrect as they do not accurately interpret the Snellen notation or misinterpret the distance at which the patient can read the eye chart.

Question 5 of 5

A 10-year-old is at the clinic for"a sore throat lasting 6 days." Which of the following would be consistent with an acute infection?

Correct Answer: D

Rationale: The correct answer is D. In an acute infection, such as streptococcal pharyngitis, the tonsils may exhibit yellowish exudates due to bacterial pus formation. This is consistent with the presence of inflammation and infection. Choices A, B, and C describe varying degrees of tonsillar enlargement and white debris, which could be present in different conditions but are not as specific to acute infection. Therefore, the presence of yellowish exudates on the tonsils is the key indicator of an acute bacterial infection like strep throat.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image