ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?
Correct Answer: C
Rationale: Rationale: 1. Recording blood pressure in lying, sitting, and standing positions helps assess for orthostatic hypotension. 2. Orthostatic hypotension can cause fainting episodes when changing positions. 3. Lying, sitting, and standing readings provide a comprehensive evaluation of blood pressure changes. 4. It helps in identifying if there is a significant drop in blood pressure from lying to standing. 5. This approach aligns with best practices in diagnosing syncope and fainting episodes. Summary of Other Choices: A. Taking blood pressure in arms and thighs is not relevant to assessing orthostatic changes. B. Only taking blood pressure in a lying position does not provide a complete evaluation of potential orthostatic issues. D. Averaging lying and sitting positions may miss important changes when transitioning to a standing position.
Question 2 of 5
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
Correct Answer: D
Rationale: Step-by-step rationale: 1. A papule is a solid, elevated lesion less than 1 cm in diameter, fitting the description. 2. A bulla is a large vesicle greater than 1 cm, not fitting the size criteria in the question. 3. A wheal is a raised, erythematous, edematous papule or plaque, not solid as described. 4. A nodule is a solid, raised lesion larger than 1 cm, not fitting the size criteria in the question. In summary, the correct answer is D (Papule) because it accurately describes the size and characteristics of the lesion in question, while the other options do not match the given description.
Question 3 of 5
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
Correct Answer: B
Rationale: The correct answer is B: Pearly gray and slightly concave. The tympanic membrane should appear pearly gray because it is composed of thin tissue. It should also appear slightly concave due to the shape and position within the ear. This indicates normal and healthy appearance. Incorrect choices: A: Light pink with a slight bulge - The tympanic membrane should not be pink, as it may indicate inflammation. A bulge could suggest fluid behind the membrane. C: Pulled in at the base of the cone of light - This could indicate negative pressure in the middle ear. D: Whitish with a small fleck of light in the superior portion - A whitish appearance may suggest infection or scarring, and a small fleck of light is not a typical finding.
Question 4 of 5
The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?
Correct Answer: A
Rationale: The correct answer is A: High-tone frequency loss. In older adults, age-related hearing loss affects high-tone frequencies first due to changes in the inner ear structures. This is considered a normal age-related change. Increased elasticity of the pinna (B) is not related to aging but rather a congenital or acquired condition. A thin, translucent membrane (C) or a shiny, pink tympanic membrane (D) may indicate issues like infection or inflammation, not normal aging changes in the ear.
Question 5 of 5
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Correct Answer: B
Rationale: The correct technique when using an otoscope to assess the nasal cavity is to avoid touching the nasal septum with the speculum. This is important because the nasal septum is a sensitive area that can be easily irritated or damaged. By avoiding contact with the septum, the nurse can prevent discomfort or potential injury to the patient. Choice A is incorrect because inserting the speculum 3 cm into the vestibule is unnecessary and may cause discomfort to the patient. Choice C is incorrect as displacing the nose can distort the anatomy and make it difficult to assess the nasal cavity accurately. Choice D is incorrect as keeping the speculum tip medial to avoid touching the floor of the nares is not a standard technique and may not provide an optimal view of the nasal cavity.