ATI RN
nclex physical and health assessment questions Questions
Question 1 of 5
Which of the following is a risk factor for ear infections in young children?
Correct Answer: D
Rationale: The correct answer is D: Second-hand cigarette smoke. Exposure to second-hand smoke can irritate and inflame the lining of the Eustachian tube, making young children more susceptible to ear infections. This is supported by research showing a clear link between exposure to cigarette smoke and increased rates of ear infections in children. Family history (A) may contribute to genetic predisposition but is not a direct risk factor. Air conditioning (B) does not directly cause ear infections. Excessive cerumen (C) can lead to blockages but is not a primary risk factor for infections.
Question 2 of 5
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?
Correct Answer: C
Rationale: The correct answer is C: Degeneration of nerves in the inner ear. This is likely the cause of the patient's hearing difficulties, as age-related degeneration of nerves in the inner ear can lead to difficulty distinguishing sounds and determining their direction. Atrophy of the apocrine glands (Choice A) and cilia becoming coarse and stiff (Choice B) are not related to hearing loss. Scarring of the tympanic membrane (Choice D) would affect sound conduction but not the perception of sound direction and clarity.
Question 3 of 5
A woman is at the clinic for a checkup and says,"My eyes have gotten puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:
Correct Answer: C
Rationale: The correct answer is C: myxedema. This is a classic presentation of hypothyroidism, specifically myxedema, characterized by puffy eyes, coarse hair, and dry skin. The thyroid hormone deficiency leads to decreased metabolic activity, causing these symptoms. Cachexia (A) is severe muscle wasting seen in conditions like cancer. Cretinism (B) is congenital hypothyroidism leading to mental retardation. Scleroderma (D) is a connective tissue disorder causing skin thickening, not typically associated with these symptoms.
Question 4 of 5
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
Correct Answer: A
Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.
Question 5 of 5
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How would the nurse proceed?
Correct Answer: C
Rationale: The correct answer is C because the nurse should use the Snellen chart positioned 6.1 m (20 ft) away to assess visual acuity. This is the standard method for testing distance vision. The nurse should ask the patient to read the letters on the chart from the top row down, covering one eye at a time if necessary. This method provides an accurate measurement of visual acuity at a distance. A: Performing the confrontation test assesses visual fields, not visual acuity. B: Using a Jaeger card is for near vision testing, not distance visual acuity. D: Assessing the ability to read newsprint at a close distance does not provide an accurate measurement of visual acuity at a distance.
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