ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
In performing a voice test to assess hearing, which of these actions would the nurse perform?
Correct Answer: B
Rationale: The correct answer is B because whispering random numbers and letters and asking the patient to repeat them is a common method used in voice tests to assess hearing ability. This test evaluates both the patient's ability to hear and understand speech at a normal conversation level. Whispering ensures that the patient relies solely on their auditory ability without any visual cues. A: Shielding the lips would hinder the patient's ability to hear the nurse clearly, making it an inappropriate action for a voice test. C: Asking the patient to occlude outside noise by placing a finger in the ear is not part of a standard voice test procedure and does not assess hearing directly. D: Standing 4 feet away doesn't provide a standardized or controlled environment for a voice test and may not accurately evaluate the patient's hearing ability.
Question 2 of 5
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: C
Rationale: The correct answer is C because by 18 months of age, it is normal for a toddler to have around 12 teeth, which usually include incisors, canines, and first molars. At this age, the child is still in the process of teething, and most children have about half of their primary teeth by 18 months. Choices A, B, and D are incorrect because asking the mother about her own teeth does not address the toddler's situation, stating that all 20 deciduous teeth should be erupted by age 4 is not accurate as teething varies, and mentioning 16 teeth by age 2-4 does not specifically address the situation at 18 months.
Question 3 of 5
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _____ comparison.
Correct Answer: A
Rationale: The correct method is side-to-side comparison. This allows for a systematic approach by ensuring all areas are examined equally. Moving side-to-side helps to maintain consistency and accuracy in assessing lung sounds. Top-to-bottom, posterior-to-anterior, and interspace-by-interspace methods may lead to missed areas or confusion in tracking progress. Side-to-side comparison is the most effective technique for thorough auscultation.
Question 4 of 5
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:
Correct Answer: B
Rationale: The correct answer is B: Postnasal drip or sinusitis. This is because a cough that worsens at night but improves during the day is a common symptom of postnasal drip or sinusitis, where mucus drips down the back of the throat when lying down. Other choices are incorrect because pneumonia typically presents with a persistent cough throughout the day, exposure to irritants at work would not cause a cough pattern specific to nighttime, and chronic bronchial irritation from smoking would result in a more persistent and continuous cough regardless of the time of day.
Question 5 of 5
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?
Correct Answer: B
Rationale: The correct answer is B because breastfeeding provides the perfect nutrition and antibodies for the baby, promoting optimal growth and immunity. It is essential for the baby's health and development. Incorrect answers: A: Breastfed babies are not necessarily more colicky; this statement is misleading. C: Breastfed babies may feed more frequently initially but not necessarily throughout infancy. D: Breastfeeding may not come naturally to every woman, as it can be challenging for some due to various reasons.