ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:
Correct Answer: D
Rationale: The correct answer is D: Trichotillomania; her child probably has a habit of absentmindedly twirling her hair. Trichotillomania is a psychological disorder characterized by the urge to pull out one's hair. In this case, the irregularly shaped patches with broken-off, stublike hair suggest hair pulling rather than a medical condition like folliculitis (A), traumatic alopecia (B), or tinea capitis (C). Folliculitis is a bacterial infection of hair follicles, not related to hair pulling. Traumatic alopecia is hair loss due to physical damage, not consistent with the described symptoms. Tinea capitis is a fungal infection causing hair loss and is not typically associated with broken-off, stublike hair. Trichotillomania is the most likely explanation given the presentation of the child's hair condition.
Question 2 of 5
The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?
Correct Answer: B
Rationale: The correct answer is B: Hypomobility. In otitis media, there is an accumulation of fluid in the middle ear, which can lead to decreased mobility of the tympanic membrane. This can be observed during pneumatic otoscopy when the tympanic membrane does not move normally in response to insufflation. Choices A, C, and D are incorrect. A) A red and bulging tympanic membrane is more indicative of acute otitis media. C) Retraction with landmarks clearly visible is a sign of negative pressure in the middle ear, possibly indicating eustachian tube dysfunction. D) A flat, slightly pulled in at the center, and moves with insufflation is characteristic of a normal tympanic membrane.
Question 3 of 5
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Recognize that this situation requires immediate intervention. If the nurse is unable to suction the nares and pass a catheter through, it suggests a potential blockage or obstruction in the nasal passages, which could lead to respiratory distress. Immediate intervention is crucial to ensure the newborn's airway is clear and breathing is not compromised. Contacting the physician or seeking further medical assistance promptly is necessary to address the issue. Choice A is incorrect because simply attempting to suction again may not resolve the underlying obstruction, and delaying necessary intervention could be harmful. Choice C is incorrect as scheduling an appointment for the infant at a later time is not appropriate when immediate intervention is required. Choice D is not applicable as it does not provide any solution or guidance for the current situation.
Question 4 of 5
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
Correct Answer: C
Rationale: Step 1: Understand the costal angle is the angle formed by the ribcage at the sternum. Step 2: A costal angle of approximately 90 degrees is within the normal range (normal is 90-120 degrees). Step 3: This angle allows for proper expansion of the lungs during breathing. Step 4: Choices A, B, and D are incorrect as they describe conditions or characteristics that are not associated with a normal costal angle. Summary: Option C is correct because a costal angle of approximately 90 degrees is a normal finding in a healthy adult, allowing for proper respiratory function.
Question 5 of 5
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary consolidation. Bronchophony is a finding in which spoken words are heard distinctly and clearly through the stethoscope, indicating increased lung density. This is commonly seen in pulmonary consolidation, where air-filled lung tissue becomes filled with fluid or solid material. This can be caused by conditions such as pneumonia or lung tumors. Assessing for signs of pulmonary consolidation, such as increased tactile fremitus, dullness to percussion, and crackles on auscultation, is crucial. Choices A, B, and D are incorrect because bronchophony is not typically associated with these conditions. Airway obstruction, emphysema, and asthma have different characteristic auscultation findings and are not directly linked to bronchophony.