ATI RN
health assessment practice questions Questions
Question 1 of 5
When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.
Correct Answer: C
Rationale: The correct answer is C, parotid and submandibular glands. The parotid and submandibular glands are the two pairs of salivary glands that are accessible for examination in the face. The parotid gland is located near the ear, while the submandibular gland is located under the jaw. The other choices are incorrect because: A: Occipital and submental glands are not salivary glands accessible for examination in the face. B: Parotid gland is correct, but jugulodigastric gland is not a salivary gland. D: Submandibular gland is correct, but occipital gland is not a salivary gland.
Question 2 of 5
During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small, compared with an enlarged cranium. On further examination, the nurse also notes dilated scalp veins and downcast, or"setting sun," eyes. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.
Question 3 of 5
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess will be:
Correct Answer: C
Rationale: The correct answer is C: at the level of the C7 vertebra. The vertebra prominens refers to the spinous process of the C7 vertebra, which is the most prominent bony landmark at the base of the neck. Assessing this area allows the nurse to accurately locate and evaluate tenderness reported by the physician. Choices A, B, and D are incorrect as they do not correspond to the location of the vertebra prominens. Option A is too high, above the diaphragm; option B is too low, lateral to the knee cap; and option D is too low, at the level of the T11 vertebra.
Question 4 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 5 of 5
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: C
Rationale: Step 1: Swollen and bleeding gums during pregnancy can be a sign of gingivitis or pregnancy gingivitis. Step 2: Dental check-ups during pregnancy are important to prevent potential complications. Step 3: Referring the woman to a dentist ensures proper evaluation and treatment. Step 4: Dental care is safe during pregnancy, so timely intervention is crucial. Step 5: Option C is correct as it addresses the concern with a proactive approach.
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