ATI RN
RN Vital Signs Assessment ATI Questions
Question 1 of 5
A patient in a physicians office has a single blood pressure (BP) reading of 150/92. Should the patient be taught about hypertension?
Correct Answer: C
Rationale: A single BP of 150/92 isn't enough for hypertension teaching, per the answer key, needing multiple readings (e.g., JNC 8). Time or gender don't determine this. High enough overlooks confirmation. Nurses educate based on trends.
Question 2 of 5
Jean has just given birth 6 months ago and is breast-feeding her child. She has not had a period since giving birth. What does this most likely represent?
Correct Answer: B
Rationale: The correct answer is B: Secondary amenorrhea. After childbirth, it is common for women who are breastfeeding to experience a temporary absence of menstruation, known as lactational amenorrhea. This is a type of secondary amenorrhea, where menstruation ceases temporarily due to factors like breastfeeding. Primary amenorrhea refers to the absence of menstruation by age 16 without any previous periods. Oligomenorrhea is infrequent or irregular periods, not the total absence of periods. Dysmenorrhea is severe menstrual pain, not the absence of menstruation.
Question 3 of 5
Which of the following is most likely benign on breast examination?
Correct Answer: B
Rationale: The correct answer is B: One breast larger than the other. This is most likely benign because breast asymmetry is common and often not a sign of serious health issues. Other choices are incorrect: A - dimpling resembling an orange peel is concerning for breast cancer, C - inverted nipple can be a sign of underlying breast pathology, D - dimpling in a breast when leaning forward could indicate an underlying mass or tumor.
Question 4 of 5
Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration?
Correct Answer: C
Rationale: The correct answer is C: Bronchial. Bronchial sounds are louder and higher in pitch compared to vesicular and bronchovesicular sounds. There is a short silence between inspiration and expiration, characteristic of bronchial sounds. Additionally, expiration is longer than inspiration in bronchial sounds. Bronchovesicular sounds have equal inspiration and expiration phases, vesicular sounds are softer and lower in pitch, and tracheal sounds are harsh and heard over the trachea.
Question 5 of 5
The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
Correct Answer: D
Rationale: The correct answer is D. This response indicates the patient is fully oriented to person, place, and time. The patient knows their name, location (hospital in Spokane), and the general time frame (February of a new year—2010). Knowing the specific month and year demonstrates a good level of orientation. Choice A is incorrect because the patient is unsure of their location and gives a vague answer about the year. Choice B is incorrect as the patient admits to being confused about the date. Choice C is incorrect because the patient does not know the date, which is an important aspect of orientation.