ATI RN
health assessment practice questions Questions
Question 1 of 5
In a patient with anisocoria, the nurse would expect to observe:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.
Question 2 of 5
The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.
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 nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:
Correct Answer: C
Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.
Question 5 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.
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