ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:
Correct Answer: A
Rationale: The correct answer is A because infants at 7 months typically turn their head to localize sound. This is a normal auditory milestone indicating the infant's ability to hear and respond to auditory stimuli. Turning the head shows awareness and localization of the sound source. Choices B, C, and D are incorrect as they do not reflect the typical auditory response expected from a 7-month-old. Choice B suggests no response, which would be concerning for hearing impairment. Choice C refers to a startle reflex, which is not the expected response to auditory stimuli at this age. Choice D describes a behavior more indicative of focused attention rather than auditory localization.
Question 2 of 5
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
Correct Answer: A
Rationale: The correct answer is A because a smooth glossy dorsal surface of the tongue is not a normal finding in adults. This could indicate atrophic glossitis, which may be due to nutritional deficiencies or other health issues. Choice B is incorrect because a thin white coating over the tongue can be a normal variation or may indicate minor issues like oral thrush. Choice C is incorrect as raised papillae on the dorsal surface is a normal finding, especially in smokers or individuals with certain oral health conditions. Choice D is incorrect as visible venous patterns on the ventral surface are also a normal finding and not considered abnormal.
Question 3 of 5
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:
Correct Answer: A
Rationale: The correct answer is A: Dullness. Atelectasis is a condition where there is complete or partial collapse of the lung. When percussing over an area of atelectasis, the sound produced is dull due to the lack of air in the affected lung tissue, which dampens the sound transmission. This is in contrast to normal lung tissue, which produces a resonant sound due to the presence of air. Tympany is a drum-like sound heard over air-filled structures like the stomach, not over atelectatic lung tissue. Hyperresonance is an abnormally loud, low-pitched sound heard in conditions like emphysema, not atelectasis.
Question 4 of 5
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?
Correct Answer: C
Rationale: The correct answer is C because it includes the most relevant nodes for assessing a woman's axillary lymph system. The central, lateral, pectoral, and subscapular nodes are key areas to examine for any abnormalities or signs of inflammation. The central nodes are located in the central axillary line, the lateral nodes are along the upper humerus, the pectoral nodes are near the pectoralis major muscle, and the subscapular nodes are beneath the scapula. These nodes drain lymph from different parts of the breast and upper extremities, making them essential for evaluating the axillary lymph system. The other choices are incorrect because they either do not include all the necessary nodes or include nodes that are less relevant for this specific assessment.
Question 5 of 5
The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?
Correct Answer: A
Rationale: The correct answer is A because nipples in different planes (deviated) can indicate a potential abnormality like a breast mass or underlying breast tissue changes. This can be a sign of asymmetry or a structural issue that warrants further evaluation. Choices B, C, and D are not considered abnormal findings during the inspection phase of breast examination. Choice B is a common and normal variation in breast size, while choice C indicates stretch marks which are common and not concerning. Choice D describes a normal finding of increased vascularity during pregnancy.