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

During the assessment of a 26-year-old, she states,"I have a spot on my lip I think is cancer." The nurse notes the following: a cluster of clear vesicles with an erythematous base around them located at the lip"� skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Correct Answer: C

Rationale: The correct answer is C because the presentation of clear vesicles with an erythematous base around them at the lip-skin border is characteristic of herpes simplex virus 1 infection, commonly known as cold sores. Given the patient's recent travel to Hawaii, exposure to the virus is likely. This infection is self-limiting and typically heals in 4 to 10 days without the need for specific treatment. Choice A is incorrect because seeing a skin specialist may not be necessary for a self-limiting viral infection. Choice B is incorrect as a biopsy is not typically indicated for a clear clinical diagnosis of herpes simplex virus infection. Choice D is incorrect as riboflavin deficiency does not present with clear vesicles and erythema at the lip-skin border.

Question 2 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 3 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 4 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 5 of 5

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

Correct Answer: D

Rationale: The presence of black and white dots on the tympanic membrane and ear canal wall during an otoscopic examination suggests a yeast or fungal infection. This is because yeast or fungal infections commonly present as white or black dots in the ear canal. Malignancy would typically manifest as abnormal growths or masses, not dots. Viral infections usually do not present as specific dots on the tympanic membrane. Blood in the middle ear would appear as red or pinkish fluid behind the eardrum, not as black and white dots. Therefore, the correct answer is D: Yeast or fungal infection.

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