ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
Jean has just given birth 6 months ago and is breast-feeding her child. She has not had a period since giving birth. What does this most likely represent?
Correct Answer: B
Rationale: The correct answer is B: Secondary amenorrhea. After childbirth, it is common for women who are breastfeeding to experience a temporary absence of menstruation, known as lactational amenorrhea. This is a type of secondary amenorrhea, where menstruation ceases temporarily due to factors like breastfeeding. Primary amenorrhea refers to the absence of menstruation by age 16 without any previous periods. Oligomenorrhea is infrequent or irregular periods, not the total absence of periods. Dysmenorrhea is severe menstrual pain, not the absence of menstruation.
Question 2 of 5
Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration?
Correct Answer: C
Rationale: The correct answer is C: Bronchial. Bronchial sounds are louder and higher in pitch compared to vesicular and bronchovesicular sounds. There is a short silence between inspiration and expiration, characteristic of bronchial sounds. Additionally, expiration is longer than inspiration in bronchial sounds. Bronchovesicular sounds have equal inspiration and expiration phases, vesicular sounds are softer and lower in pitch, and tracheal sounds are harsh and heard over the trachea.
Question 3 of 5
The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
Correct Answer: D
Rationale: The correct answer is D. This response indicates the patient is fully oriented to person, place, and time. The patient knows their name, location (hospital in Spokane), and the general time frame (February of a new year—2010). Knowing the specific month and year demonstrates a good level of orientation. Choice A is incorrect because the patient is unsure of their location and gives a vague answer about the year. Choice B is incorrect as the patient admits to being confused about the date. Choice C is incorrect because the patient does not know the date, which is an important aspect of orientation.
Question 4 of 5
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, 'I quit smoking after my wife died 7 years ago.' However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the discrepancy between the patient's statement and the observation made by the nurse. By using confrontation in a non-judgmental manner, the nurse can bring attention to the inconsistency and encourage Mr. K. to clarify his tobacco use accurately. This approach promotes honesty and trust between the nurse and the patient. Choice A is incorrect because it is accusatory and may lead to defensiveness from the patient. Choice B is also incorrect as it does not address the observed behavior and may not effectively resolve the discrepancy. Choice C is invalid as it shifts the focus away from the issue of tobacco use and towards the patient's personal life, which is not the primary concern in this scenario.
Question 5 of 5
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
Correct Answer: B
Rationale: The correct answer is B: Use a Doppler device to check for pulsations. This is the best action because a Doppler device can detect blood flow even when pulses are weak or difficult to palpate. A: Auscultating with a fetoscope is not suitable for assessing pulses. C: Checking for pulsations with a goniometer is used to measure joint angles, not pulses. D: Using a stethoscope to auscultate the pulse may not provide accurate information compared to a Doppler device.