ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?
Correct Answer: B
Rationale: The correct answer is B: Rubella can damage the infant's organ of Corti, which will impair hearing. Rubella virus can cross the placenta and infect the developing fetus, leading to congenital rubella syndrome. This syndrome can cause damage to various organs including the organ of Corti in the inner ear, leading to hearing impairment. This occurs mainly when the infection happens during the first trimester when the organ systems are developing. Incorrect choices: A: Rubella may affect the mother's hearing but not the infant's - This is incorrect as rubella can indeed affect the infant's hearing through congenital rubella syndrome. C: Rubella is only dangerous to the infant in the second trimester of pregnancy - This is incorrect as rubella can harm the infant's hearing in the first trimester as well. D: Rubella can impair the development of CN VIII and thus affect hearing - While rubella can affect hearing, it primarily does so by damaging the organ of Corti
Question 2 of 5
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Recognize that this situation requires immediate intervention. If the nurse is unable to suction the nares and pass a catheter through, it suggests a potential blockage or obstruction in the nasal passages, which could lead to respiratory distress. Immediate intervention is crucial to ensure the newborn's airway is clear and breathing is not compromised. Contacting the physician or seeking further medical assistance promptly is necessary to address the issue. Choice A is incorrect because simply attempting to suction again may not resolve the underlying obstruction, and delaying necessary intervention could be harmful. Choice C is incorrect as scheduling an appointment for the infant at a later time is not appropriate when immediate intervention is required. Choice D is not applicable as it does not provide any solution or guidance for the current situation.
Question 3 of 5
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
Correct Answer: C
Rationale: Step 1: Understand the costal angle is the angle formed by the ribcage at the sternum. Step 2: A costal angle of approximately 90 degrees is within the normal range (normal is 90-120 degrees). Step 3: This angle allows for proper expansion of the lungs during breathing. Step 4: Choices A, B, and D are incorrect as they describe conditions or characteristics that are not associated with a normal costal angle. Summary: Option C is correct because a costal angle of approximately 90 degrees is a normal finding in a healthy adult, allowing for proper respiratory function.
Question 4 of 5
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary consolidation. Bronchophony is a finding in which spoken words are heard distinctly and clearly through the stethoscope, indicating increased lung density. This is commonly seen in pulmonary consolidation, where air-filled lung tissue becomes filled with fluid or solid material. This can be caused by conditions such as pneumonia or lung tumors. Assessing for signs of pulmonary consolidation, such as increased tactile fremitus, dullness to percussion, and crackles on auscultation, is crucial. Choices A, B, and D are incorrect because bronchophony is not typically associated with these conditions. Airway obstruction, emphysema, and asthma have different characteristic auscultation findings and are not directly linked to bronchophony.
Question 5 of 5
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
Correct Answer: D
Rationale: Step 1: After menopause, hormonal changes lead to a decrease in estrogen levels. Step 2: Decreased estrogen causes glandular and fat tissue in the breasts to atrophy. Step 3: Atrophy of glandular and fat tissue results in diminished breast size and elasticity. Step 4: Diminished size and elasticity lead to breasts sagging. Step 5: Therefore, option D is correct as it accurately explains the physiological process behind breast sagging after menopause. Summary: Option A is incorrect as breast sagging can occur in women with any breast size. Option B is incorrect as breast sagging is not primarily due to decreased muscle mass. Option C is incorrect as protein intake does not directly prevent breast sagging caused by tissue atrophy.