ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:
Correct Answer: D
Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important because chronic lung disease can lead to mouth breathing, causing dryness in the mouth. Dry mouth can increase the risk of oral health issues and affect overall well-being. A: "Do you use a fluoride supplement?" is not directly related to the patient's history of hypertension and chronic lung disease. B: "Have you had tonsillitis in the last year?" is not as relevant to the patient's current conditions as dryness in the mouth. C: "At what age did you get your first tooth?" is not pertinent to the patient's current health status and medical history.
Question 2 of 5
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:
Correct Answer: A
Rationale: The correct answer is A: Dullness. Atelectasis is a condition where there is complete or partial collapse of the lung. When percussing over an area of atelectasis, the sound produced is dull due to the lack of air in the affected lung tissue, which dampens the sound transmission. This is in contrast to normal lung tissue, which produces a resonant sound due to the presence of air. Tympany is a drum-like sound heard over air-filled structures like the stomach, not over atelectatic lung tissue. Hyperresonance is an abnormally loud, low-pitched sound heard in conditions like emphysema, not atelectasis.
Question 3 of 5
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?
Correct Answer: C
Rationale: The correct answer is C because it includes the most relevant nodes for assessing a woman's axillary lymph system. The central, lateral, pectoral, and subscapular nodes are key areas to examine for any abnormalities or signs of inflammation. The central nodes are located in the central axillary line, the lateral nodes are along the upper humerus, the pectoral nodes are near the pectoralis major muscle, and the subscapular nodes are beneath the scapula. These nodes drain lymph from different parts of the breast and upper extremities, making them essential for evaluating the axillary lymph system. The other choices are incorrect because they either do not include all the necessary nodes or include nodes that are less relevant for this specific assessment.
Question 4 of 5
The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?
Correct Answer: A
Rationale: The correct answer is A because nipples in different planes (deviated) can indicate a potential abnormality like a breast mass or underlying breast tissue changes. This can be a sign of asymmetry or a structural issue that warrants further evaluation. Choices B, C, and D are not considered abnormal findings during the inspection phase of breast examination. Choice B is a common and normal variation in breast size, while choice C indicates stretch marks which are common and not concerning. Choice D describes a normal finding of increased vascularity during pregnancy.
Question 5 of 5
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?
Correct Answer: C
Rationale: The correct answer is C because smoking, hypertension, obesity, diabetes, and high cholesterol are all major risk factors for heart disease supported by research. Smoking damages blood vessels, hypertension increases heart strain, obesity leads to various heart issues, diabetes affects blood sugar levels, and high cholesterol can lead to plaque buildup in arteries. Choice A is incorrect because stress is not a major risk factor for heart disease compared to the other factors listed. Choice B is incorrect as personality type is not a significant risk factor for heart disease. Choice D is incorrect because alcohol consumption is not as strongly associated with heart disease as the other factors listed in choice C.