ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: Lyme disease. The bull's eye rash, also known as erythema migrans, is a classic symptom of Lyme disease, caused by the bacterium Borrelia burgdorferi transmitted through tick bites. This distinctive rash pattern is a key diagnostic feature. Rubeola (A) presents with a different rash pattern and symptoms. Allergy to mosquito bites (C) typically results in localized redness and swelling, not a bull's eye rash. Rocky Mountain spotted fever (D) may present with a rash, but it typically does not have the characteristic bull's eye appearance seen in Lyme disease.
Question 2 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 3 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 4 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.
Question 5 of 5
A woman in her 26th week of pregnancy states that she is 'not really short of breath' but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?
Correct Answer: C
Rationale: The correct answer is C because in the 26th week of pregnancy, it is normal for women to experience an increased awareness of their breathing without actual shortness of breath. This is due to the growing fetus putting pressure on the diaphragm, leading to a sensation of needing to breathe more frequently. The nurse's response should reassure the woman that her experience is normal and not a cause for concern. Choice A is incorrect because the diaphragm does not become fixed during pregnancy, rather it is pushed upward by the growing uterus. Choice B is incorrect because although estrogen levels increase during pregnancy, causing changes in the rib cage, this does not directly lead to difficulty in breathing. Choice D is incorrect because the increased awareness of breathing is not solely due to the increased oxygen demand from the fetus but also from the physical changes in the body due to pregnancy.