ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection?
Correct Answer: C
Rationale: The correct answer is C because tonsils that are 3+/1-4+ with large white spots are indicative of exudative tonsillitis, which commonly occurs in acute bacterial infections like streptococcal pharyngitis. Here's the rationale: 1. Tonsils 3+ indicate significant enlargement, more than the normal size. 2. 1-4+ refers to the extent of the white spots or exudate present on the tonsils. 3. Large white spots suggest a substantial amount of exudate, commonly seen in bacterial infections like streptococcal pharyngitis. Therefore, the presentation of enlarged tonsils with large white spots aligns with an acute bacterial infection. Other choices are incorrect: A: Tonsils are not significantly enlarged nor do they have white spots. B: While there is white debris, it is not extensive as indicated by the 1-4+ scale. D: Pale coloring does not indicate an
Question 2 of 5
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
Correct Answer: B
Rationale: The correct answer is B: When part of the lung is obstructed or collapsed. Unequal chest expansion can occur when there is an obstruction or collapse of a portion of the lung, leading to decreased lung expansion on that side. This can result in one side of the chest moving less during breathing. Other options are incorrect because: A: In an obese patient - obesity may affect chest wall movement but does not directly cause unequal chest expansion. C: When bulging of the intercostal spaces is present - bulging of intercostal spaces may indicate increased work of breathing but does not necessarily lead to unequal chest expansion. D: When accessory muscles are used to augment respiratory effort - while accessory muscles may be used in respiratory distress, they do not directly cause unequal chest expansion.
Question 3 of 5
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?
Correct Answer: D
Rationale: The correct answer is D because the statement accurately describes colostrum, the first milk produced during pregnancy. Colostrum is a thick, yellow fluid that can be expressed from the breasts as early as the fourth month of pregnancy. It is rich in antibodies and nutrients essential for the newborn. A: Incorrect. Breast milk does not immediately appear after delivery; it takes a few days for mature milk to come in. B: Incorrect. Breast milk is rich in fat, not just protein and sugars. Fat is crucial for a baby's growth and development. C: Incorrect. Colostrum is a nutrient-rich fluid that provides essential nutrients to the newborn, even though it may not have the same composition as mature breast milk. In summary, choice D is correct because it accurately describes the early milk production during pregnancy, while the other choices provide inaccurate information about breast milk.
Question 4 of 5
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities. A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.
Question 5 of 5
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
Correct Answer: B
Rationale: The correct answer is B because listening in a rough Z pattern allows the nurse to cover all areas where heart sounds can be best heard - aortic, pulmonic, tricuspid, and mitral. This technique ensures a systematic approach to auscultation, starting at the base of the heart and moving towards the apex where the mitral area is located. By inching the stethoscope in this pattern, the nurse can accurately identify any abnormalities in heart sounds. Choice A is incorrect as it does not provide a systematic approach to auscultation and may lead to missing certain areas. Choice C is incorrect as heart sounds should be listened to at all relevant areas, not just where the apical pulse is strongest. Choice D is incorrect as listening for all possible sounds at once may lead to confusion and missing subtle abnormalities.