ATI RN
nclex practice questions 2023 health assessment Questions
Question 1 of 5
When assessing inflammation in a dark-skinned person, the nurse may need to:
Correct Answer: C
Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.
Question 2 of 5
The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.
Question 3 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 4 of 5
A patient reports a severe throbbing headache in the frontotemporal area of his head that he experienced while studying for an examination, He says that the headache was somewhat relieved when he lay down. He tells the nurse that his mother also used to get these headaches. The nurse suspects that he may be suffering from:
Correct Answer: D
Rationale: The correct answer is D: migraine headaches. The patient's symptoms of severe throbbing headache in the frontotemporal area, triggered by stress (studying for an exam), partially relieved by lying down, and family history of similar headaches are indicative of migraines. Migraines commonly present with these characteristics, often exacerbated by stress and have a genetic component. A: Hypertension does not typically present with throbbing headaches in a specific area or relief with lying down. B: Cluster headaches are characterized by severe, unilateral headaches around the eye area, not frontotemporal. C: Tension headaches usually present as dull, constant pressure-type headaches, not throbbing, and do not have the familial pattern described by the patient.
Question 5 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.
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