ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
All of the following patients have a body temperature of 38 C (100.4 F). About which patient would a nurse be most concerned?
Correct Answer: D
Rationale: A 2-month-old with 38°C raises most concern, per the answer key, due to immature immunity and fever's risk in infants. Older adults , pregnant teens , and athletes better tolerate this. Nurses prioritize infants for urgent evaluation.
Question 2 of 5
A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable. What visible skin change of the breast does she have?
Correct Answer: A
Rationale: The correct answer is A: Nipple retraction. Nipple retraction is characterized by the inward pulling of the nipple, which can be associated with underlying breast pathology such as breast cancer. In this case, a flattened nipple deviating towards the lateral side indicates nipple retraction, which is concerning for malignancy. Other choices are incorrect: B) Paget's disease presents with eczematous changes around the nipple; C) Peau d'orange sign refers to skin dimpling resembling an orange peel, seen in inflammatory breast cancer; D) No option provided.
Question 3 of 5
A 62-year-old construction worker presents with chronic cough and occasional shortness of breath for almost a year. He has smoked two packs a day for 45 years. On examination, his chest diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields.
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). Given the patient's history of smoking, chronic cough, shortness of breath, and decreased breath sounds, COPD is the most likely diagnosis. COPD is characterized by irreversible airflow obstruction due to chronic inflammation and damage to the lungs, commonly caused by smoking. The enlarged chest diameter and decreased breath sounds suggest hyperinflation and air trapping, which are typical in COPD. Rhonchi can be heard due to airway inflammation and mucus production. Incorrect choices: A: Spontaneous pneumothorax - Unlikely as there is no sudden onset of chest pain or breathlessness. C: Asthma - Less likely in this case as asthma typically presents with wheezing and may have a history of allergies. D: Pneumonia - Less likely given the chronic nature of the symptoms and absence of fever or focal chest signs.
Question 4 of 5
The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
Correct Answer: C
Rationale: Rationale for Correct Answer C: 1. Normal Aging Process: It is normal for older adults to take a little longer to respond due to age-related changes in cognitive processing speed. 2. General Knowledge and Abilities: The patient's general knowledge and abilities should not have declined significantly just due to age. 3. Overall Mental Status: Despite potential slower response times, the patient's mental status should be intact in terms of memory, attention, and orientation. Summary of Other Choices: A. Incorrect - Unrealistic expectation as aging typically results in some decline in cognitive abilities. B. Incorrect - While remote memory may decline with age, it is not a guarantee for all individuals. D. Incorrect - Response time may be slower, but loss of language and general knowledge is not necessarily expected solely due to age.
Question 5 of 5
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. This is because the patient's emotional response (laughing loudly) does not match the content of the picture (decapitated head), which is considered inappropriate. Confusion (A) refers to a lack of understanding, ambivalence (B) is conflicting feelings, and depersonalization (C) is feeling disconnected from oneself, none of which fully explain the patient's behavior. Inappropriate affect best describes the mismatch between the patient's emotional expression and the situation presented.