ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin?
Correct Answer: C
Rationale: The correct answer is C, ashen, gray, or dull. In a black patient with impending shock, the skin often appears ashen or gray due to poor perfusion. This is a result of decreased blood flow and oxygen to the skin, indicating a serious condition. Choice A, ruddy blue, is incorrect as it suggests cyanosis, which is more common in Caucasians. Generalized pallor, choice B, is unlikely in a black patient due to the natural skin pigmentation. Patchy areas of pallor, choice D, are less indicative of impending shock compared to a more uniform ashen or gray appearance.
Question 2 of 5
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: A
Rationale: The correct answer is A: "Does your baby seem to startle with loud noises?" This question is relevant because exposure to aspirin during pregnancy can potentially lead to hearing loss in the infant. Aspirin is known to cause ototoxicity, affecting the auditory nerve and leading to hearing problems. Therefore, asking about the baby's response to loud noises can help identify any potential hearing issues related to the aspirin exposure during pregnancy. Choices B, C, and D are incorrect because they focus on ear-related issues, such as surgeries, drainage, and infections. While these are valid concerns, they are not directly related to the potential hearing loss caused by aspirin exposure during pregnancy. Hence, these options are less relevant in this context compared to the correct answer, which directly addresses the possible consequence of aspirin intake during pregnancy on the infant's hearing.
Question 3 of 5
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: D
Rationale: The correct response is D: "She is just starting to salivate and hasn't learned to swallow the saliva." At 3 months old, infants often start drooling due to increased salivation as their salivary glands develop. This response acknowledges normal infant development and provides an explanation for the observed behavior. Choice A (You're right, drooling is usually a sign of the first tooth) is incorrect because while drooling can be associated with teething, it is not the primary reason for drooling in a 3-month-old. Choice B (It would be unusual for a 3-month-old to be getting her first tooth) is incorrect because teething can start as early as 3 months, although it is more common around 6 months. Choice C (This could be the sign of a problem with the salivary glands) is incorrect as it jumps to a less likely conclusion of a salivary gland issue without considering the normal developmental process of salivation in infants
Question 4 of 5
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
Correct Answer: C
Rationale: The correct answer is C: "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." Rationale: 1. Black, hairy tongue is a known side effect of prolonged antibiotic use, leading to fungal overgrowth. 2. Antibiotics can disrupt the natural balance of bacteria in the mouth, allowing fungi to overgrow. 3. Fungal infections can manifest as a black, hairy appearance on the tongue. 4. Biopsy is not typically needed for the diagnosis of black, hairy tongue. 5. Overgrowth of hair is not a plausible explanation for this condition. 6. The black, hairy tongue is not caused by the same bacteria the patient had in his lungs. Summary: Choice C is correct as it accurately links the patient's antibiotic use to the fungal infection causing black, hairy tongue. Choices A, B, and D are incorrect as they do not address the specific cause of this condition and provide inaccurate information.
Question 5 of 5
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
Correct Answer: A
Rationale: The correct answer is A, between the scapulae. Tactile fremitus is most intense over areas where there is a solid lung structure close to the chest wall, such as between the scapulae where the main bronchi are located. This proximity allows for better transmission of vibrations generated by vocalization. Choices B, C, and D are incorrect because they do not align with the anatomical locations of solid lung structures. The third intercostal space, midaxillary line, and lower lobes do not provide the necessary proximity to produce intense tactile fremitus.