ATI RN
Assess Vital Signs Questions
Question 1 of 5
In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because performing the otoscopic examination at the end of the assessment allows the nurse to build rapport with the child first, reducing anxiety and increasing cooperation. This approach also prevents the child from becoming upset or uncooperative due to discomfort during the examination. Additionally, it ensures that the child's comfort and trust are prioritized during the assessment process. Choice A is incorrect because omitting the otoscopic examination based on the child having a fever can lead to missing important diagnostic information. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended practice and can cause discomfort to the child. Choice C is incorrect as it is important for the mother to be present to provide comfort and support to the child during the examination.
Question 2 of 5
When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, the papillae on the tongue tend to flatten, resulting in a smoother appearance. This is a normal part of the aging process. Choice A is incorrect as teeth appearing shorter is more likely due to wear and tear or dental issues. Choice C, beefy red buccal mucosa, may indicate inflammation or infection, not necessarily related to aging. Choice D, a painless lump on the dorsum of the tongue, should be further investigated as it could be a sign of a more serious condition.
Question 3 of 5
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:
Correct Answer: C
Rationale: The correct answer is C: Vesicular breath sounds and normal in that location. Vesicular breath sounds are low-pitched, soft sounds heard over most of the lung fields. In this case, they are heard over the posterior lower lobes, which is a normal location for vesicular sounds. The longer inspiration than expiration is also characteristic of vesicular breath sounds. A: Normally auscultated over the trachea - This is incorrect as breath sounds over the trachea are typically harsh and high-pitched. B: Bronchial breath sounds and normal in that location - Bronchial breath sounds are harsh, loud sounds heard over the trachea and are not normal in the posterior lower lobes. D: Bronchovesicular breath sounds and normal in that location - Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, and they are not normally auscultated in the posterior lower lobes.
Question 4 of 5
Which of the following statements is true regarding the internal structures of the breast? The breast is made up of:
Correct Answer: B
Rationale: Rationale: 1. The breast is composed of fibrous tissue, which provides structural support. 2. Glandular tissue is present for milk production. 3. Adipose tissue is essential for storing energy and padding. 4. Option A is incorrect as the breast contains minimal muscle tissue. 5. Option C is incorrect as lactiferous ducts are part of the milk delivery system, not the entire breast. 6. Option D is incorrect as glandular tissue does not attach to the chest wall.
Question 5 of 5
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?
Correct Answer: D
Rationale: Answer D is correct because having a first-degree relative (mother) with breast cancer is a significant risk factor for developing breast cancer. This increases the individual's risk compared to the general population. Choice A (37-year-old who is slightly overweight) is not a direct risk factor for breast cancer. Choice B (42-year-old who has had ovarian cancer) is not a known risk factor for breast cancer, although there is a link between ovarian and breast cancer. Choice C (45-year-old who has never been pregnant) is a risk factor for breast cancer but not as significant as having a family history of the disease.