ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician?
Correct Answer: C
Rationale: The correct answer is C: Every 3 years. This is based on American Cancer Society recommendations for women aged 20-39 to have a clinical breast examination every 3 years. This frequency ensures regular monitoring without unnecessary burden on the individual. The other choices are incorrect because annual screenings (A) may lead to overdiagnosis and unnecessary procedures, every 2 years (B) may not provide sufficient monitoring, and every 4 years (D) extends the gap between screenings too much, potentially missing early signs of breast cancer. A 3-year interval strikes a balance between regular monitoring and avoiding excessive testing.
Question 2 of 5
The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl's mental status?
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential regression in the girl's social development, preferring to play with younger children. This behavior may suggest difficulty in forming age-appropriate relationships or social skills, which could be concerning in the context of her parents' divorce. Choice A may indicate attachment issues, but it is common for young children to cling to their primary caregiver in stressful situations. Choice B describes a common emotional response to stress but does not necessarily indicate a mental health concern. Choice C is a typical behavior for a 5-year-old and does not raise immediate concerns about her mental status.
Question 3 of 5
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, 'I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!' Which of these responses by the nurse uses empathy?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Response C acknowledges the mother's feelings without judgment, showing understanding and empathy. 2. It validates her emotions by acknowledging the difficulty she is facing. 3. It does not assume or imply any specific emotion, allowing the mother to express herself freely. 4. Responses A and B are close but do not fully capture the depth of empathy displayed in response C. 5. Response D lacks empathy as it focuses more on agreement rather than truly understanding and validating the mother's emotions.
Question 4 of 5
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
Correct Answer: B
Rationale: The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.
Question 5 of 5
The nurse is examining a school-age child. Which approach is best?
Correct Answer: B
Rationale: The correct answer is B because involving the child in the process and explaining equipment helps build trust, reduces anxiety, and promotes cooperation. This approach empowers the child, respects their autonomy, and facilitates a positive healthcare experience. Choice A is incorrect as rushing the examination may increase the child's anxiety. Choice C is incorrect as having a parent present can provide comfort and support. Choice D is incorrect as the focus should be on the child for effective assessment and communication.