ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A patient with a middle ear infection asks the nurse, 'What does the middle ear do?' The nurse responds by telling the patient that the middle ear functions to:
Correct Answer: C
Rationale: The correct answer is C: Conduct vibrations of sounds to the inner ear. The middle ear consists of the eardrum and three small bones that transmit sound vibrations from the eardrum to the inner ear. This process allows sound waves to be converted into electrical signals that can be interpreted by the brain. Choice A is incorrect because balance is primarily controlled by structures in the inner ear, not the middle ear. Choice B is incorrect as interpreting sounds happens in the inner ear and brain, not the middle ear. Choice D is incorrect because the middle ear does not increase the amplitude of sound; rather, it amplifies and transmits sound vibrations to the inner ear for further processing.
Question 2 of 5
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
Correct Answer: B
Rationale: The correct answer is B: Firm pressure. When palpating sinus areas, normal findings should elicit a sensation of firm pressure. This is because the sinuses are air-filled cavities that should not cause pain or discomfort when palpated. Sensing firm pressure indicates normal sinus function. Choices A, C, and D are incorrect because normal sinus palpation should not result in no sensation, pain during palpation, or pain sensation behind the eyes. These sensations could indicate sinus inflammation, infection, or other abnormalities that should be further assessed.
Question 3 of 5
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
Correct Answer: D
Rationale: The correct response is D. Using nasal medications can irritate the nasal lining, leading to rebound swelling, which causes the medication to become less effective over time. This explains why the woman's nasal spray is not working as well as before. It is important for the nurse to address this issue to prevent worsening of symptoms. Choice A is incorrect as not all over-the-counter nasal sprays carry a risk of addiction. Choice B is not the best response as switching brands may not address the underlying issue of rebound swelling. Choice C is incorrect as it does not address the potential problem of rebound swelling caused by the nasal spray.
Question 4 of 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
Correct Answer: B
Rationale: The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management. Incorrect choices: A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold. C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent. D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.
Question 5 of 5
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? Tell the mother that:
Correct Answer: C
Rationale: The correct answer is C because unilateral breast enlargement with tenderness in a 10-year-old girl is most likely due to normal breast development, known as thelarche. The nurse should reassure the mother that it is common for breast development to be asymmetric initially and that an examination can confirm this. This response is appropriate because breast cancer is extremely rare in preadolescent girls, making option B incorrect. Option A is incorrect as immediate examination is not necessary unless there are other concerning symptoms. Option D is incorrect as breast tenderness can occur during breast development due to hormonal changes. Thus, option C is the best response based on the presentation and age of the patient.