nclex physical and health assessment questions

Questions 46

ATI RN

Home > ATI RN > Health Assessment > nclex physical and health assessment questions
ATI RN Test Bank

nclex physical and health assessment questions Questions

Question 1 of 5

The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?

Correct Answer: B

Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.

Question 2 of 5

A patient's medical record describes a lesion that is confluent in nature. On examination, the nurse would expect to find:

Correct Answer: A

Rationale: The correct answer is A: lesions that run together. Confluent lesions refer to merging or blending of individual lesions to form a larger lesion. This indicates a continuous area of involvement on the skin. Choices B, C, and D do not accurately describe confluent lesions as they refer to different patterns of lesion distribution such as annular, linear, or grouped. The key to identifying confluent lesions is the concept of merging or running together, which is best represented by choice A.

Question 3 of 5

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Correct Answer: C

Rationale: Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms. Therefore, the correct answer is C: maxillary sinusitis.

Question 4 of 5

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o'clock position in each eye. The nurse would:

Correct Answer: C

Rationale: The correct answer is C: document this as an asymmetrical light reflex. This finding indicates an asymmetry in the corneal light reflex, suggesting a possible deviation in eye alignment or muscle weakness. It is essential to document this observation for further evaluation and monitoring. Choice A is incorrect as asymmetry in the light reflex is not a normal finding. Referring for further evaluation (Choice B) would be appropriate if the asymmetry persists or is associated with other concerning symptoms. Performing the confrontation test (Choice D) is not necessary for this specific assessment and finding.

Question 5 of 5

The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:

Correct Answer: A

Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.

Similar Questions

The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
During an interview, the patient says that he experiences a sensation as if"everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
A 70-year-old patient reports to the nurse that he is having trouble hearing, especially when he is in large groups. He says he"can't always tell where the sound is coming from" and the words often sound"mixed up." What might the nurse suspect as the cause for this?
A patient presents with excruciating pain on one side of his head, especially around his eye, forehead, and cheek, that occurs once or twice each day and lasts about 30 minutes to 2 hours. The nurse suspects:
What would be a normal finding when assessing the lacrimal apparatus during an eye examination?

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