ATI RN
Assessing Vital Signs Questions
Question 1 of 5
A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies. On examination, auscultation of her chest shows decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs.
Correct Answer: C
Rationale: The correct answer is C: Asthma. The key clues in the scenario are the patient's age, nocturnal cough, continuous shortness of breath, history of seasonal allergies, and physical exam findings of wheezing on expiration in all lobes. These are classic signs of asthma. Asthma is a chronic inflammatory condition of the airways characterized by reversible airflow obstruction, leading to symptoms such as cough, shortness of breath, and wheezing. The patient's history of seasonal allergies further supports the diagnosis of asthma, as allergies are a common trigger for asthma exacerbations. Now, let's discuss why the other choices are incorrect: A: Spontaneous pneumothorax typically presents with sudden-onset chest pain and shortness of breath, not a gradual onset as described in the scenario. B: Chronic obstructive pulmonary disease (COPD) is more common in older individuals with a history of smoking. The absence of smoking history and the patient's age make COPD
Question 2 of 5
A patient repeatedly seems to have difficulty coming up with a word. He says, 'I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. Circumlocution refers to the use of indirect or roundabout ways of expressing oneself, often due to difficulty in finding the right word. In this case, the patient struggles to recall the word "elevator" and instead describes it as "the thing that you step into that goes up in the air." This behavior is characteristic of circumlocution. Blocking (A) refers to a sudden interruption in train of thought or speech production, which is not evident in this scenario. Neologism (B) is the creation of new words or phrases, which is not demonstrated here. Circumstantiality (D) involves unnecessary and excessive detail in conversation, which is not the primary issue in this case.
Question 3 of 5
During a visit to the clinic, a patient states, 'The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?' The nurse's most appropriate response in this case would be:
Correct Answer: B
Rationale: The correct answer is B: "Would you like some information about the different ways a person can quit smoking?" Rationale: 1. Empathy: This response shows empathy by acknowledging the patient's struggle and offering support. 2. Patient-Centered Care: By asking if the patient would like information, the nurse involves the patient in decision-making. 3. Education: Providing information about quitting smoking empowers the patient to make an informed choice. 4. Non-judgmental: This response avoids judgment or pressure, which can help the patient feel more comfortable seeking help. Summary of Incorrect Choices: A: This response is directive and lacks empathy, potentially making the patient feel judged or pressured. C: While empathetic, this response does not offer practical help or information to address the patient's concerns. D: This response is confrontational and assumes the patient should already know about the smoking cessation program, which may come across as dismissive.
Question 4 of 5
During auscultation of the heart, the nurse hears a murmur. What instrument should be used to further assess this murmur?
Correct Answer: B
Rationale: The correct answer is B: Bell of the stethoscope. The bell of the stethoscope is used to assess low-frequency sounds like heart murmurs. Murmurs are often soft and low-pitched, requiring the bell for optimal detection. The diaphragm (Choice A) is used for high-frequency sounds. The electrocardiogram (Choice C) records the heart's electrical activity, not the physical sounds. The Doppler device (Choice D) is used to assess blood flow and velocity, not heart sounds. Therefore, the bell of the stethoscope is the appropriate instrument to further assess the heart murmur.
Question 5 of 5
During an examination of a child, the nurse considers that physical growth is the best index of a child's:
Correct Answer: A
Rationale: The correct answer is A: General health. Physical growth is a reflection of overall health status in children. Adequate growth indicates proper nutrition, absence of chronic illness, and normal development. Monitoring growth parameters like height and weight can provide valuable insights into a child's well-being. The other choices are incorrect because while genetics (B) can influence growth potential, it doesn't directly indicate the current health status. Nutritional status (C) is important for growth but doesn't encompass all aspects of health. Activity and exercise patterns (D) are important for overall health but don't solely determine a child's general health status.