ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides a physiological explanation for the child's frequent ear infections. The eustachian tube in young children is indeed shorter and wider than in adults, making it easier for infections to develop. This is due to the anatomy of the child's ear, not necessarily indicating a more severe underlying issue. Choice A is incorrect as it implies there must be something else wrong, which is not necessarily the case. Choice B is incorrect as checking the immune system may not be the first step in addressing frequent ear infections. Choice C is incorrect as cerumen is not directly related to the development of ear infections in this context.
Question 2 of 5
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:
Correct Answer: C
Rationale: The correct answer is C: Bruising on the buccal mucosa or gums. This is because bruising in the oral cavity can be indicative of physical abuse in children. The nurse should look for signs of trauma that may not be easily visible on other parts of the body. Bruising on the buccal mucosa or gums could be a result of forceful feeding, hitting, or physical abuse. A: Swollen, red tonsils - Typically not associated with child abuse unless there are other signs of trauma. B: Ulcerations on the hard palate - Unlikely to be a common sign of physical abuse in a child. D: Small yellow papules along the hard palate - Not typically associated with physical abuse; more likely related to other oral health issues. In summary, bruising on the buccal mucosa or gums is the most relevant sign to look for in this scenario as it could indicate possible child abuse.
Question 3 of 5
When assessing a patient's lungs, the nurse recalls that the left lung:
Correct Answer: A
Rationale: The correct answer is A: Consists of two lobes. The left lung indeed consists of two lobes - the upper lobe and the lower lobe, separated by the oblique fissure. The right lung, not the left lung, is divided by the horizontal fissure (B). The left lung primarily consists of the upper lobe on the anterior chest, not the posterior chest (C). The length of the lungs is not determined by the underlying organs like the stomach; it is mainly due to anatomical landmarks and structures. Therefore, option D is incorrect.
Question 4 of 5
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
Correct Answer: C
Rationale: Step 1: Bronchovesicular breath sounds are expected near the major airways. Step 2: Bronchovesicular sounds are heard over the 1st and 2nd intercostal spaces along the sternal border at the front and between the scapulae on the back. Step 3: The sounds are a combination of bronchial (heard over trachea and major bronchi) and vesicular (heard over peripheral lung fields) sounds. Step 4: The characteristics include moderate pitch and intensity, with equal inspiration and expiration. Step 5: Choice C is the correct answer as it accurately describes the expected location of bronchovesicular breath sounds near the major airways. Summary: A: Incorrect - Bronchovesicular breath sounds are not musical in quality. B: Incorrect - Bronchovesicular breath sounds are not usually caused by a pathologic disease. D: Incorrect - Bronchovesicular breath sounds are a combination of bronchial
Question 5 of 5
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?
Correct Answer: C
Rationale: The correct answer is C because gynecomastia in men is often caused by hormonal imbalances. By explaining this to the patient and recommending evaluation by a physician, the nurse ensures appropriate medical assessment and potential treatment. Choice A is incorrect because mammograms are not typically used to diagnose gynecomastia in men. Choice B is incorrect as gynecomastia should not be dismissed without further evaluation. Choice D is incorrect because gynecomastia is not always associated with prostate enlargement, and a thorough screening may not be necessary without more specific symptoms or risk factors.