ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
Correct Answer: C
Rationale: The correct answer is C, severe dehydration. Decreased skin turgor is a clinical sign of dehydration due to fluid loss, causing the skin to lose its elasticity. In contrast, severe obesity (choice A) would not typically result in decreased skin turgor. Childhood growth spurts (choice B) do not directly affect skin turgor. Connective tissue disorders like scleroderma (choice D) may affect skin quality, but decreased skin turgor specifically indicates dehydration. Therefore, choice C is the most likely condition associated with decreased skin turgor.
Question 2 of 5
The primary purpose of the ciliated mucous membrane in the nose is to:
Correct Answer: B
Rationale: The correct answer is B: Filter out dust and bacteria. The ciliated mucous membrane in the nose acts as a physical barrier to trap and remove harmful particles like dust and bacteria from the inhaled air. Here's the rationale: 1. The cilia trap particles: The cilia in the mucous membrane sweep back and forth, capturing dust and bacteria in the mucus. 2. Mucus removes particles: The sticky mucus traps the particles, preventing them from entering the respiratory system. 3. Prevents infections: By filtering out harmful particles, the mucous membrane helps protect the respiratory system from infections. 4. Other choices are incorrect: A is incorrect as the primary function is not to warm the air. C is incorrect as it focuses on coarse particles only. D is incorrect as it does not specifically address the filtration function of the mucous membrane.
Question 3 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 4 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 5 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