ATI RN
Assessing Vital Signs Questions
Question 1 of 5
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: Step-by-step rationale for why Option D is correct: 1. Hormonal changes during pregnancy can lead to increased blood flow to gums, causing them to be swollen and bleed. 2. This condition is known as pregnancy gingivitis and is a common occurrence during pregnancy. 3. The nurse should educate the woman about the link between hormonal changes and gum health. 4. Referring the woman to a dentist is important for further evaluation and management. 5. Option D is the most appropriate response as it addresses the specific issue related to pregnancy and gum health.
Question 2 of 5
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
Correct Answer: A
Rationale: The correct answer is A: Asthma. The assessment findings described are classic signs of an asthma exacerbation. Tachypnea, prolonged expiration, intercostal retractions, and expiratory wheezes are all indicative of narrowed airways and difficulty breathing, which are characteristic of asthma. The use of accessory neck muscles indicates increased effort to breathe. Decreased breath sounds are due to air trapping in the lungs. In contrast, choices B, C, and D do not typically present with the combination of symptoms described. Atelectasis usually presents with decreased breath sounds and crackles. Lobar pneumonia typically presents with fever, productive cough, and focal chest signs. Heart failure presents with bilateral crackles, edema, and jugular venous distension.
Question 3 of 5
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:
Correct Answer: B
Rationale: Rationale: Option B is correct because the nurse should gather more information to assess the patient's pain properly. This response shows active listening and empathy, facilitating a comprehensive evaluation. Option A is incorrect as it dismisses the patient's concern and provides inaccurate information about breast cancer. Option C is incorrect as it shifts the focus to the nurse's experience rather than addressing the patient's current situation. Option D is incorrect because while breast pain can be benign, assuming it is always benign without further assessment can lead to missed diagnoses.
Question 4 of 5
Which of these statements describes the closure of the valves in a normal cardiac cycle?
Correct Answer: C
Rationale: The correct answer is C because in a normal cardiac cycle, the closure of the valves follows a specific sequence. The mitral valve closes slightly before the tricuspid valve due to the ventricular pressure changes. The closure of the mitral valve marks the beginning of systole, while the tricuspid valve closes shortly after. Choices A and B are incorrect as they do not accurately describe the sequence of valve closure. Choice D is incorrect because the tricuspid and pulmonic valves do not close at the same time in a normal cardiac cycle.
Question 5 of 5
During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
Correct Answer: C
Rationale: The correct answer is C: Displacement of the heart from elevation of the diaphragm. During pregnancy, the growing uterus pushes the diaphragm upwards, causing the heart to be displaced upwards and laterally. This displacement results in the apical impulse being palpated at a higher position, such as the fourth left intercostal space lateral to the midclavicular line. This finding is a normal physiological change due to pregnancy and does not indicate any cardiac pathology. Explanation of other choices: A: Right ventricular hypertrophy - This is unlikely in a pregnant patient without underlying cardiac conditions. B: Increased volume and size of the heart as a result of pregnancy - While the heart may undergo some changes during pregnancy, palpating the apical impulse at a higher position is specifically due to displacement of the heart by the elevated diaphragm, not increased heart size. D: Increased blood flow through the internal mammary artery - This choice is unrelated to the displacement of the heart and the