ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
Correct Answer: A
Rationale: Step 1: Dry mucosa and deep vertical fissures in the tongue are classic signs of dehydration. Step 2: Dehydration can result from prolonged nausea and vomiting leading to fluid loss. Step 3: Lack of fluid intake contributes to dry mucosa and fissures in the tongue. Step 4: Therefore, the correct answer is A: Dehydration. Other choices are incorrect as they do not explain the specific physical signs observed in the patient.
Question 2 of 5
When inspecting the anterior chest of an adult, the nurse should include which assessment?
Correct Answer: D
Rationale: The correct answer is D, examining the shape and configuration of the chest wall. This assessment helps identify any abnormalities such as barrel chest or pectus excavatum. Diaphragmatic excursion (A) is assessed at the posterior chest. Symmetric chest expansion (B) is relevant for assessing lung function, not specifically the anterior chest. Presence of breath sounds (C) is important but does not specifically pertain to the anterior chest assessment.
Question 3 of 5
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? The nurse should tell her that:
Correct Answer: C
Rationale: The correct answer is C because cyclic breast changes are common due to hormonal fluctuations during the monthly menstrual cycle. This is a normal physiological process where breasts may feel different at different times of the month. It is important for the nurse to reassure the woman that these changes are normal. Choice A is incorrect as it states that continual changes in breasts are unusual, which is not accurate for nonpregnant women. Choice B is incorrect as it focuses on stress as the cause of breast changes, which is not the primary reason in this case. Choice D is incorrect as it suggests that breast changes only occur during pregnancy, which is not true as hormonal fluctuations during the menstrual cycle can also cause changes in breasts.
Question 4 of 5
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:
Correct Answer: B
Rationale: The correct answer is B. Palpating the unaffected breast first allows for establishing a baseline for comparison, aiding in identifying any differences in texture, size, or tenderness. This approach helps in assessing the lump in the left breast effectively. Palpating the affected breast first (choice A) may lead to missing important comparisons. Avoiding palpation due to potential cyst rupture (choice C) is incorrect as palpation is necessary for assessment. Palpating the breast with the lump first but the axilla last (choice D) is not ideal as it doesn't prioritize establishing a baseline for accurate assessment.
Question 5 of 5
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
Correct Answer: D
Rationale: The correct answer is D: Fifth left intercostal space at the midclavicular line. The apical impulse, also known as the point of maximal impulse (PMI), is the point on the chest wall where the heartbeat is most easily palpated. It is normally located at the fifth intercostal space at the midclavicular line, which aligns with the apex of the heart. Palpating this area allows the nurse to assess the location, size, and strength of the heartbeat. Choices A, B, and C are incorrect because they do not correspond to the typical location of the apical impulse.