ATI RN
Assess Vital Signs Questions
Question 1 of 5
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia is the difficulty or discomfort in swallowing, which can occur after a stroke due to facial muscle weakness. In this case, the right-sided facial drooping indicates a stroke affecting the left side of the brain, which can lead to dysphagia. Epistaxis (nosebleed) and rhinorrhea (runny nose) are not typically associated with facial drooping after a stroke. Xerostomia (dry mouth) is more related to salivary gland dysfunction and is not directly related to facial muscle weakness.
Question 2 of 5
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:
Correct Answer: C
Rationale: The correct answer is C: Vesicular breath sounds and normal in that location. Vesicular breath sounds are low-pitched, soft sounds heard over most of the lung fields. In this case, they are heard over the posterior lower lobes, which is a normal location for vesicular sounds. The longer inspiration than expiration is also characteristic of vesicular breath sounds. A: Normally auscultated over the trachea - This is incorrect as breath sounds over the trachea are typically harsh and high-pitched. B: Bronchial breath sounds and normal in that location - Bronchial breath sounds are harsh, loud sounds heard over the trachea and are not normal in the posterior lower lobes. D: Bronchovesicular breath sounds and normal in that location - Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, and they are not normally auscultated in the posterior lower lobes.
Question 3 of 5
Which of the following statements is true regarding the internal structures of the breast? The breast is made up of:
Correct Answer: B
Rationale: Rationale: 1. The breast is composed of fibrous tissue, which provides structural support. 2. Glandular tissue is present for milk production. 3. Adipose tissue is essential for storing energy and padding. 4. Option A is incorrect as the breast contains minimal muscle tissue. 5. Option C is incorrect as lactiferous ducts are part of the milk delivery system, not the entire breast. 6. Option D is incorrect as glandular tissue does not attach to the chest wall.
Question 4 of 5
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?
Correct Answer: D
Rationale: Answer D is correct because having a first-degree relative (mother) with breast cancer is a significant risk factor for developing breast cancer. This increases the individual's risk compared to the general population. Choice A (37-year-old who is slightly overweight) is not a direct risk factor for breast cancer. Choice B (42-year-old who has had ovarian cancer) is not a known risk factor for breast cancer, although there is a link between ovarian and breast cancer. Choice C (45-year-old who has never been pregnant) is a risk factor for breast cancer but not as significant as having a family history of the disease.
Question 5 of 5
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age?
Correct Answer: B
Rationale: Correct Answer: B - Increase in systolic blood pressure Rationale: 1. Age-related vascular changes lead to decreased arterial compliance. 2. Decreased arterial compliance results in increased systolic blood pressure. 3. This explains the elevated systolic blood pressure in the 70-year-old man. Other Choices: A. Increase in resting heart rate - Not typically age-related; may indicate other issues. C. Decrease in diastolic blood pressure - Usually remains stable or slightly increases with age. D. Increase in diastolic blood pressure - Not a common age-related change; may indicate other underlying conditions.