ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and 'stuck on' his skin. Which is the best prediction?
Correct Answer: D
Rationale: The correct answer is D: Seborrheic keratoses, which do not become cancerous. Seborrheic keratoses are benign skin growths that are typically greasy, dark, and have a 'stuck on' appearance. They are not cancerous and do not pose a risk of developing into skin cancer. This is important to reassure the patient and alleviate their concerns. A: Senile lentigines are also known as age spots and are benign pigmented spots that do not typically become cancerous. B: Actinic keratoses are precancerous lesions that can develop into squamous cell carcinoma if left untreated. C: Acrochordons, also known as skin tags, are benign growths and not precursors to squamous cell carcinoma. In summary, the other choices are incorrect because they either refer to benign conditions that do not become cancerous (A and C) or precancerous lesions that can progress to skin cancer (
Question 2 of 5
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:
Correct Answer: A
Rationale: The correct answer is A because infants at 7 months typically turn their head to localize sound. This is a normal auditory milestone indicating the infant's ability to hear and respond to auditory stimuli. Turning the head shows awareness and localization of the sound source. Choices B, C, and D are incorrect as they do not reflect the typical auditory response expected from a 7-month-old. Choice B suggests no response, which would be concerning for hearing impairment. Choice C refers to a startle reflex, which is not the expected response to auditory stimuli at this age. Choice D describes a behavior more indicative of focused attention rather than auditory localization.
Question 3 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 4 of 5
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
Correct Answer: A
Rationale: The correct answer is A because a smooth glossy dorsal surface of the tongue is not a normal finding in adults. This could indicate atrophic glossitis, which may be due to nutritional deficiencies or other health issues. Choice B is incorrect because a thin white coating over the tongue can be a normal variation or may indicate minor issues like oral thrush. Choice C is incorrect as raised papillae on the dorsal surface is a normal finding, especially in smokers or individuals with certain oral health conditions. Choice D is incorrect as visible venous patterns on the ventral surface are also a normal finding and not considered abnormal.
Question 5 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.