ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
Correct Answer: B
Rationale: The correct answer is B: Dry mucous membranes and cracked lips. Dehydration leads to reduced moisture in the body, resulting in dryness of mucous membranes and lips. This is a sign of fluid imbalance and severe dehydration. Smooth mucous membranes (choice A) may indicate adequate hydration. Pale mucous membranes (choice C) could suggest anemia or poor perfusion, not solely dehydration. White patches on mucous membranes (choice D) are usually associated with fungal infections, not dehydration.
Question 2 of 5
The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?
Correct Answer: C
Rationale: The correct action is pulling the pinna up and back before inserting the speculum. This helps straighten the ear canal for better visualization. Tilting the head forward (A) does not aid in the examination. Releasing traction (B) can cause the speculum to move out of place. Using the smallest speculum (D) may not provide adequate visualization.
Question 3 of 5
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?
Correct Answer: C
Rationale: The correct answer is C, decreased ability to identify odors, for an 80-year-old patient due to age-related changes. As people age, the sense of smell tends to decline, affecting the ability to identify odors accurately. This is a common phenomenon in older adults due to changes in olfactory receptors and decreased sensitivity. Hypertrophy of the gums (A) is not typically associated with aging. Increased production of saliva (B) is not a common age-related change. Finer and less prominent nasal hair (D) is more likely to occur in younger individuals due to hormonal changes rather than in older adults.
Question 4 of 5
The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:
Correct Answer: A
Rationale: The correct answer is A: Acquired immunodeficiency syndrome (AIDS). The dark red confluent macule on the hard palate is known as Kaposi sarcoma, a common manifestation of AIDS. This lesion can be the first visible sign of AIDS in patients with a history of intravenous drug abuse. It is important for the nurse to recognize this early sign to facilitate prompt diagnosis and treatment. Measles (choice B) typically presents with a widespread rash, not a localized lesion on the hard palate. Leukemia (choice C) may present with oral manifestations, but a dark red macule on the hard palate is not a typical finding. Carcinoma (choice D) refers to cancer, which may present differently in the oral cavity compared to Kaposi sarcoma.
Question 5 of 5
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? 'Tactile fremitus:
Correct Answer: C
Rationale: The correct understanding of tactile fremitus is that it is caused by sounds generated from the larynx and transmitted through the bronchopulmonary system to the chest wall. This vibration is felt by the hand during palpation. Moisture in the alveoli (choice A) does not cause tactile fremitus. Air in the subcutaneous tissues (choice B) does not relate to tactile fremitus. Blood flow through the pulmonary arteries (choice D) is not associated with tactile fremitus. The correct answer, choice C, is supported by the fact that tactile fremitus is a physical sensation felt by the hands due to the transmission of sound through the chest wall.