ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
Correct Answer: C
Rationale: In the context of a patient with sensorineural hearing loss, it is crucial for the nurse to ask the patient what medications he is currently taking (Option C). This is the correct answer because sensorineural hearing loss is often caused by factors like aging, genetics, or exposure to loud noise, and certain medications can also contribute to hearing impairment. By inquiring about the patient's current medications, the nurse can gather important information to assess potential medication-induced hearing loss and facilitate appropriate interventions or referrals. Option A, speaking loudly, is incorrect as it does not address the underlying cause of sensorineural hearing loss and may not be effective for the patient. Option B, assessing for a middle ear infection, is also incorrect because sensorineural hearing loss typically originates from the inner ear or auditory nerve, not the middle ear. Option D, looking for an obstruction in the external ear, is not relevant for sensorineural hearing loss, which is usually related to damage in the inner ear structures. In an educational context, understanding the underlying causes of sensorineural hearing loss and the importance of medication history in assessing hearing health is essential for nurses to provide comprehensive and individualized care to patients with hearing impairments. This question highlights the significance of a thorough assessment and tailored interventions based on the specific needs of patients with sensorineural hearing loss.
Question 2 of 5
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
Correct Answer: D
Rationale: Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.
Question 3 of 5
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of:
Correct Answer: B
Rationale: The correct answer is B) Increased vascularity in the upper respiratory tract as a result of pregnancy. During pregnancy, hormonal changes lead to an increase in blood volume and circulation, causing the blood vessels in the upper respiratory tract to become more dilated and fragile. This increased vascularity can result in common pregnancy symptoms such as nasal congestion, nosebleeds, and nasal stuffiness. Option A) A problem with the patient's coagulation system is incorrect because nosebleeds during pregnancy are typically due to increased vascularity rather than a coagulation disorder. Option C) Increased susceptibility to colds and nasal irritation is not the primary reason for nosebleeds in pregnancy. While pregnant women may be more prone to respiratory infections, the increased vascularity is the main factor contributing to nosebleeds. Option D) Inappropriate use of nasal sprays is not the cause in this scenario unless the woman is using nasal sprays excessively or inappropriately. However, the most likely reason for her nosebleeds is the physiological changes related to pregnancy. Educationally, understanding the physiological changes that occur during pregnancy and their impact on various body systems, including the respiratory system, is crucial for healthcare providers to provide appropriate care and support to pregnant individuals. Recognizing common symptoms like nosebleeds as a result of increased vascularity can help nurses and other healthcare professionals address these issues effectively and reassure patients that they are experiencing normal pregnancy-related changes.
Question 4 of 5
The nurse knows that auscultation of fine crackles would most likely be noticed in:
Correct Answer: C
Rationale: In this scenario, option C, "The immediate newborn period," is the correct answer. Fine crackles, also known as fine rales, are the result of fluid in the small airways or alveoli. In the immediate newborn period, it is common for newborns to have transient tachypnea and retained lung fluid, which can lead to the presence of fine crackles upon auscultation. Option A, a healthy 5-year-old child, is incorrect because fine crackles are not typically heard in healthy children without underlying respiratory conditions. Option B, a pregnant woman, is also incorrect as fine crackles are not a common finding in pregnant women unless there are pre-existing respiratory issues. Option D, association with a pneumothorax, is incorrect as crackles associated with a pneumothorax would typically be described as pleural friction rubs rather than fine crackles. From an educational standpoint, understanding the significance of fine crackles in different clinical contexts is crucial for accurate assessment and diagnosis. It highlights the importance of recognizing age-specific variations in normal and abnormal findings during physical assessments, particularly in vulnerable populations like newborns. This knowledge helps nurses provide appropriate care and interventions based on their assessment findings.
Question 5 of 5
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
Correct Answer: A
Rationale: The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk), may be expressed from the breasts.