health assessment practice questions

Questions 45

ATI RN

ATI RN Test Bank

health assessment practice questions Questions

Question 1 of 5

The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?

Correct Answer: A

Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.

Question 2 of 5

During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.

Question 3 of 5

An 85-year-old female patient is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse provide?

Correct Answer: C

Rationale: The correct answer is C because as individuals age, there is a natural decrease in skin elasticity, subcutaneous fat, and moisture content in the skin. These factors contribute to the bones becoming more noticeable in the face. Choice A is incorrect because diets low in protein and high in carbohydrates do not directly cause enlargement of facial bones. Choice B is incorrect as the use of a specific moisturizer does not directly impact the visibility of facial bones. Choice D is incorrect because facial skin actually loses elasticity with age, leading to less taut skin and more prominent bones.

Question 4 of 5

A patient has a normal pupillary light reflex. The nurse recognizes this to indicate that:

Correct Answer: D

Rationale: The correct answer is D because a normal pupillary light reflex involves the constriction of both pupils in response to bright light. This reflex is controlled by the autonomic nervous system, specifically the parasympathetic nervous system. When light is detected by the retina, signals are sent to the brain which then triggers the constriction of both pupils to reduce the amount of light entering the eye. Choices A, B, and C are incorrect because they do not accurately describe the pupillary light reflex. Vision convergence, light reflection, and focusing the image at the center of the pupil are not directly related to the pupillary light reflex.

Question 5 of 5

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure?

Correct Answer: C

Rationale: The correct answer is C: Tilt the child's head slightly toward the examiner. This position straightens the ear canal, facilitating visualization. Pulling the pinna down (A) can cause discomfort and obstruct the view. Pulling the pinna up and back (B) is incorrect for a child under 3 years old as it straightens the ear canal in adults. Having the child touch his chin to his chest (D) is unnecessary and may lead to improper examination positioning.

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