ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Is caused by increased sebum production. Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. During puberty, hormonal changes can lead to an increase in sebum production, which can contribute to the development of acne. By understanding this connection, the 13-year-old girl can better grasp the underlying cause of her acne and make informed decisions about her skincare routine and treatment options. Option A) Is contagious, is incorrect because acne is not a contagious condition. It is not spread through touch or sharing items like towels or makeup. Option B) Has no known cause, is incorrect because we do know that acne is primarily caused by factors like hormonal changes, genetics, and increased sebum production, as mentioned above. Option D) Has been found to be related to poor hygiene, is incorrect because while good hygiene practices can help prevent acne, poor hygiene alone does not directly cause acne. It is more about the factors mentioned earlier like hormonal changes and sebum production. This question provides valuable information for the 13-year-old girl about the physiological basis of acne, empowering her to take control of her skincare regimen and make informed choices about managing her condition. Understanding the cause of acne can also help dispel common myths and misconceptions surrounding this common skin issue.
Question 2 of 5
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
Correct Answer: C
Rationale: In the context of a patient with sensorineural hearing loss, it is crucial for the nurse to ask the patient what medications he is currently taking (Option C). This is the correct answer because sensorineural hearing loss is often caused by factors like aging, genetics, or exposure to loud noise, and certain medications can also contribute to hearing impairment. By inquiring about the patient's current medications, the nurse can gather important information to assess potential medication-induced hearing loss and facilitate appropriate interventions or referrals. Option A, speaking loudly, is incorrect as it does not address the underlying cause of sensorineural hearing loss and may not be effective for the patient. Option B, assessing for a middle ear infection, is also incorrect because sensorineural hearing loss typically originates from the inner ear or auditory nerve, not the middle ear. Option D, looking for an obstruction in the external ear, is not relevant for sensorineural hearing loss, which is usually related to damage in the inner ear structures. In an educational context, understanding the underlying causes of sensorineural hearing loss and the importance of medication history in assessing hearing health is essential for nurses to provide comprehensive and individualized care to patients with hearing impairments. This question highlights the significance of a thorough assessment and tailored interventions based on the specific needs of patients with sensorineural hearing loss.
Question 3 of 5
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:
Correct Answer: A
Rationale: An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.
Question 4 of 5
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
Correct Answer: D
Rationale: Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.
Question 5 of 5
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of:
Correct Answer: B
Rationale: The correct answer is B) Increased vascularity in the upper respiratory tract as a result of pregnancy. During pregnancy, hormonal changes lead to an increase in blood volume and circulation, causing the blood vessels in the upper respiratory tract to become more dilated and fragile. This increased vascularity can result in common pregnancy symptoms such as nasal congestion, nosebleeds, and nasal stuffiness. Option A) A problem with the patient's coagulation system is incorrect because nosebleeds during pregnancy are typically due to increased vascularity rather than a coagulation disorder. Option C) Increased susceptibility to colds and nasal irritation is not the primary reason for nosebleeds in pregnancy. While pregnant women may be more prone to respiratory infections, the increased vascularity is the main factor contributing to nosebleeds. Option D) Inappropriate use of nasal sprays is not the cause in this scenario unless the woman is using nasal sprays excessively or inappropriately. However, the most likely reason for her nosebleeds is the physiological changes related to pregnancy. Educationally, understanding the physiological changes that occur during pregnancy and their impact on various body systems, including the respiratory system, is crucial for healthcare providers to provide appropriate care and support to pregnant individuals. Recognizing common symptoms like nosebleeds as a result of increased vascularity can help nurses and other healthcare professionals address these issues effectively and reassure patients that they are experiencing normal pregnancy-related changes.