ATI RN
Assess Vital Signs Questions
Question 1 of 5
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:
Correct Answer: D
Rationale: The correct answer is D: Cutis marmorata. Cutis marmorata is a transient mottling of the skin that occurs in response to cold temperatures, common in newborns with Down syndrome. This occurs due to immature vasomotor control and resolves with warmth. Choice A, Café au lait, refers to light brown skin pigmentation and is not related to mottling. Choice B, Carotenemia, is yellow-orange discoloration of the skin from excessive carotene intake, not related to mottling. Choice C, Acrocyanosis, is bluish discoloration of the extremities due to poor circulation, not mottling.
Question 2 of 5
In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because performing the otoscopic examination at the end of the assessment allows the nurse to build rapport with the child first, reducing anxiety and increasing cooperation. This approach also prevents the child from becoming upset or uncooperative due to discomfort during the examination. Additionally, it ensures that the child's comfort and trust are prioritized during the assessment process. Choice A is incorrect because omitting the otoscopic examination based on the child having a fever can lead to missing important diagnostic information. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended practice and can cause discomfort to the child. Choice C is incorrect as it is important for the mother to be present to provide comfort and support to the child during the examination.
Question 3 of 5
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia is the difficulty or discomfort in swallowing, which can occur after a stroke due to facial muscle weakness. In this case, the right-sided facial drooping indicates a stroke affecting the left side of the brain, which can lead to dysphagia. Epistaxis (nosebleed) and rhinorrhea (runny nose) are not typically associated with facial drooping after a stroke. Xerostomia (dry mouth) is more related to salivary gland dysfunction and is not directly related to facial muscle weakness.
Question 4 of 5
When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, the papillae on the tongue tend to flatten, resulting in a smoother appearance. This is a normal part of the aging process. Choice A is incorrect as teeth appearing shorter is more likely due to wear and tear or dental issues. Choice C, beefy red buccal mucosa, may indicate inflammation or infection, not necessarily related to aging. Choice D, a painless lump on the dorsum of the tongue, should be further investigated as it could be a sign of a more serious condition.
Question 5 of 5
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:
Correct Answer: C
Rationale: The correct answer is C: Vesicular breath sounds and normal in that location. Vesicular breath sounds are low-pitched, soft sounds heard over most of the lung fields. In this case, they are heard over the posterior lower lobes, which is a normal location for vesicular sounds. The longer inspiration than expiration is also characteristic of vesicular breath sounds. A: Normally auscultated over the trachea - This is incorrect as breath sounds over the trachea are typically harsh and high-pitched. B: Bronchial breath sounds and normal in that location - Bronchial breath sounds are harsh, loud sounds heard over the trachea and are not normal in the posterior lower lobes. D: Bronchovesicular breath sounds and normal in that location - Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, and they are not normally auscultated in the posterior lower lobes.