ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
Correct Answer: B
Rationale: The correct answer is B because auscultating an apical rate for 1 minute allows for a more accurate assessment of the infant's heart rate, which can vary. This method helps detect any abnormalities, such as sinus arrhythmia commonly seen in infants. Auscultating the apical rate is more accurate than palpating the radial pulse in infants due to their small size and delicate nature. Assessing blood pressure in infants requires specialized equipment, not just a stethoscope with a large diaphragm piece. Observing the chest for respiratory rate is important but does not provide a full assessment of vital signs.
Question 2 of 5
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description matches the characteristic rash of measles, known as Koplik spots. These spots typically appear before the onset of the classic maculopapular rash that starts behind the ears and spreads to the face and body. Measles is highly contagious, and Koplik spots are a hallmark sign. A: Pink, papular rash on the face and neck - This description does not match the presentation of measles. B: Pruritic vesicles over her trunk and neck - This description is more indicative of conditions like chickenpox, not measles. C: Hyperpigmentation on the chest, abdomen, and back of the arms - This description does not align with the symptoms of measles.
Question 3 of 5
The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?
Correct Answer: A
Rationale: Step 1: Air conduction is the normal pathway for hearing, where sound waves travel through the outer ear canal, eardrum, middle ear bones, and into the cochlea in the inner ear. Step 2: Vibrations of the bones in the skull (choice B) refer to bone conduction, not air conduction. Step 3: Amplitude of sound (choice C) determines loudness, not pitch. Step 4: Loss of air conduction (choice D) is called conductive hearing loss, but this is not the true statement about air conduction.
Question 4 of 5
In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?
Correct Answer: D
Rationale: Rationale: In otitis externa, the infection usually involves the outer ear canal and surrounding tissues. Enlarged superficial cervical nodes are a common sign due to the lymphatic drainage in the area. Rhinorrhea (A) is associated with nasal congestion, not ear infections. Periorbital edema (B) is seen in conditions affecting the eyes or surrounding tissues. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa. Ultimately, D is the correct answer as it aligns with the typical presentation of otitis externa.
Question 5 of 5
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
Correct Answer: A
Rationale: Step 1: Dry mucosa and deep vertical fissures in the tongue are classic signs of dehydration. Step 2: Dehydration can result from prolonged nausea and vomiting leading to fluid loss. Step 3: Lack of fluid intake contributes to dry mucosa and fissures in the tongue. Step 4: Therefore, the correct answer is A: Dehydration. Other choices are incorrect as they do not explain the specific physical signs observed in the patient.