ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A 17-year-old high school senior presents to your clinic in acute respiratory distress with sudden right-sided chest pain and severe shortness of breath. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe.
Correct Answer: A
Rationale: The correct answer is A: Spontaneous pneumothorax. This condition involves the accumulation of air in the pleural space, leading to lung collapse. In this case, the absence of breath sounds, hyperresonance on percussion, and absent fremitus on palpation are classic signs of pneumothorax. The sudden onset of symptoms in a young individual, particularly with chest pain and shortness of breath, further support this diagnosis. Choices B, C, and D can be ruled out: B: Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation, typically seen in older individuals with a history of smoking. This does not fit the acute presentation in a young patient. C: Asthma is a chronic inflammatory condition that causes reversible airway obstruction, often presenting with wheezing and cough, which are not seen in this patient. D: Pneumonia is an infection of the lung tissue, usually presenting with fever,
Question 2 of 5
A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
Correct Answer: A
Rationale: The correct answer is A: Has a snake phobia. The patient's persistent and irrational fear of snakes that interferes with his daily life indicates a phobia. Phobias are characterized by an intense fear of a specific object or situation, leading to avoidance behaviors. In this case, the patient's fear of snakes is excessive and unreasonable, causing significant distress. It is not a hypochondriac (B) because the fear is specific to snakes and not related to health concerns. It is not an obsession (C) because the fear of snakes is not driven by intrusive thoughts or compulsive behaviors. It is not a delusion (D) because the fear is not based on a false belief, but rather an irrational fear.
Question 3 of 5
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, 'You don't smoke, drink, or take drugs, do you?' This question is an example of:
Correct Answer: C
Rationale: The correct answer is C: Using biased or leading questions. This question is leading because it assumes that the patients don't smoke, drink, or take drugs. It may influence the patients to answer in a certain way to please the nurse. This can result in inaccurate information being provided. Talking too much (A), using confrontation (B), and using blunt language (D) do not accurately describe the nature of the question being asked.
Question 4 of 5
When examining an older adult, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because older adults may have mobility issues, so minimizing position changes during the exam helps prevent discomfort or falls. This approach promotes patient safety and comfort. Choice A is incorrect as appropriate touch is essential for a thorough assessment. Choice B is incorrect as older adults may tire easily, so breaking up the exam into manageable parts is preferable. Choice C is incorrect as speaking loudly and slowly may be perceived as patronizing and is not necessary unless the patient has hearing difficulties.
Question 5 of 5
The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
Correct Answer: C
Rationale: The correct answer is C because kyphosis and flexion in the knees and hips are common age-related changes in older adults. Kyphosis is the forward curvature of the spine, and flexion in the knees and hips can occur due to joint stiffness and muscle weakness. These changes are considered normal in older adults. Option A is incorrect because an increase in body weight is not necessarily normal with aging. Option B is incorrect as additional fat deposits on specific body parts may not necessarily be considered normal. Option D is incorrect because a change in overall body proportion with a longer trunk and shorter extremities is not a typical age-related change.