ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: C
Rationale: The correct answer is C because by 18 months of age, it is normal for a toddler to have around 12 teeth, which usually include incisors, canines, and first molars. At this age, the child is still in the process of teething, and most children have about half of their primary teeth by 18 months. Choices A, B, and D are incorrect because asking the mother about her own teeth does not address the toddler's situation, stating that all 20 deciduous teeth should be erupted by age 4 is not accurate as teething varies, and mentioning 16 teeth by age 2-4 does not specifically address the situation at 18 months.
Question 2 of 5
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:
Correct Answer: B
Rationale: The correct answer is B: Postnasal drip or sinusitis. This is because a cough that worsens at night but improves during the day is a common symptom of postnasal drip or sinusitis, where mucus drips down the back of the throat when lying down. Other choices are incorrect because pneumonia typically presents with a persistent cough throughout the day, exposure to irritants at work would not cause a cough pattern specific to nighttime, and chronic bronchial irritation from smoking would result in a more persistent and continuous cough regardless of the time of day.
Question 3 of 5
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?
Correct Answer: B
Rationale: The correct answer is B because breastfeeding provides the perfect nutrition and antibodies for the baby, promoting optimal growth and immunity. It is essential for the baby's health and development. Incorrect answers: A: Breastfed babies are not necessarily more colicky; this statement is misleading. C: Breastfed babies may feed more frequently initially but not necessarily throughout infancy. D: Breastfeeding may not come naturally to every woman, as it can be challenging for some due to various reasons.
Question 4 of 5
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
Correct Answer: A
Rationale: Step-by-step rationale: 1. During pregnancy, blood pressure tends to decrease due to hormonal and physiological changes. 2. The decline in blood pressure is attributed to peripheral vasodilatation, allowing for increased blood flow to the placenta. 3. This vasodilatation is a normal adaptive response to support the growing fetus. 4. The parasympathetic effect of pregnancy hormones contributes to the vasodilatation and helps regulate blood pressure. 5. Therefore, choice A is correct as it aligns with the physiological changes expected during pregnancy. Summary of other choices: - Choice B incorrectly attributes the decline solely to the parasympathetic effect, ignoring the role of vasodilatation. - Choice C is incorrect as a decrease in blood pressure does not necessarily mean a decrease in cardiac output during pregnancy. - Choice D is incorrect as a decrease in blood pressure does not always indicate a dangerous decrease in blood volume for the fetus.
Question 5 of 5
A patient reports severe abdominal pain. The nurse begins with:
Correct Answer: C
Rationale: The correct answer is C: Inspection to note visible abnormalities. Inspection is the initial assessment technique used to observe visible signs such as distention, discoloration, or scars. This helps in gathering important information about the patient's condition before proceeding to palpation or percussion. Light palpation (choice A) and deep palpation (choice B) involve touching the abdomen, which may worsen the pain or miss important visual clues. Percussion (choice D) is typically used after inspection and palpation to assess organ density, not as the initial step in assessing abdominal pain.