ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A 62-year-old construction worker presents with chronic cough and occasional shortness of breath for almost a year. He has smoked two packs a day for 45 years. On examination, his chest diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields.
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). Given the patient's history of smoking, chronic cough, shortness of breath, and decreased breath sounds, COPD is the most likely diagnosis. COPD is characterized by irreversible airflow obstruction due to chronic inflammation and damage to the lungs, commonly caused by smoking. The enlarged chest diameter and decreased breath sounds suggest hyperinflation and air trapping, which are typical in COPD. Rhonchi can be heard due to airway inflammation and mucus production. Incorrect choices: A: Spontaneous pneumothorax - Unlikely as there is no sudden onset of chest pain or breathlessness. C: Asthma - Less likely in this case as asthma typically presents with wheezing and may have a history of allergies. D: Pneumonia - Less likely given the chronic nature of the symptoms and absence of fever or focal chest signs.
Question 2 of 5
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. This is because the patient's emotional response (laughing loudly) does not match the content of the picture (decapitated head), which is considered inappropriate. Confusion (A) refers to a lack of understanding, ambivalence (B) is conflicting feelings, and depersonalization (C) is feeling disconnected from oneself, none of which fully explain the patient's behavior. Inappropriate affect best describes the mismatch between the patient's emotional expression and the situation presented.
Question 3 of 5
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
Correct Answer: D
Rationale: The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.
Question 4 of 5
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Be mindful of the child's modesty. This is the most appropriate action because it respects the child's privacy and helps build trust. Starting with the genitalia (B) can be invasive and inappropriate. Talking about equipment (A) may not address the child's emotional needs. Performing a head-to-toe assessment starting with the chest (D) may overlook the importance of considering the child's comfort and modesty. Being mindful of modesty shows respect for the child's dignity and autonomy.
Question 5 of 5
The nurse should measure rectal temperatures in which of these patients?
Correct Answer: C
Rationale: The correct answer is C because rectal temperatures are most accurate in patients who are unable to hold a thermometer in their mouth, such as comatose adults. Rectal temperatures closely reflect core body temperature. Choice A (school-age child) may be able to hold a thermometer in their mouth. Choice B (older adult) may have conditions affecting rectal tissue. Choice D (patient receiving oxygen by nasal cannula) may have altered oxygen levels affecting temperature readings.