ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
Correct Answer: C
Rationale: The correct answer is C because a newborn's skin is more permeable than that of an adult, making them more susceptible to fluid loss. This is due to the thinner and less developed skin barrier in newborns, which can lead to increased transepidermal water loss. A: Subcutaneous fat deposits being high in the newborn would actually help with insulation and temperature regulation, reducing the risk of fluid loss. B: Sebaceous glands being overproductive in the newborn would contribute to skin lubrication and protection, not fluid loss. D: The presence of vernix caseosa helps to protect the infant's skin and prevent excessive fluid loss, so an increase in vernix caseosa would not lead to fluid loss.
Question 2 of 5
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Cerumen, also known as earwax, serves to protect the ear canal by trapping dust and debris, preventing infections, and lubricating the skin. Its composition helps maintain the pH balance in the ear, preventing bacterial growth. Therefore, the statement that "the purpose of cerumen is to protect and lubricate the ear" is correct. Summary of Incorrect Choices: A: Sticky honey-colored cerumen is not necessarily a sign of infection. Cerumen can vary in color and consistency. B: The presence of cerumen does not solely indicate poor hygiene. It is a natural substance produced by the body. D: While cerumen can affect sound conduction if impacted, it is not necessary for transmitting sound through the auditory canal. Sound waves travel through the eardrum and middle ear to the cochlea.
Question 3 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 4 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 5 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.