ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's skin. Which technique should be used to best assess skin temperature?
Correct Answer: B
Rationale: The correct answer is B: Dorsal surface of the hand. This is because the dorsal surface of the hand is less sensitive to temperature variations compared to the palmar surface, allowing for a more accurate assessment of skin temperature. Using the fingertips may lead to inaccurate results due to their high sensitivity to temperature changes. The ulnar portion of the hand is not commonly used for assessing skin temperature. Overall, the dorsal surface of the hand provides a more reliable and consistent assessment of skin temperature due to its lower sensitivity to temperature changes.
Question 2 of 5
A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?
Correct Answer: C
Rationale: Rationale: 1. Recording blood pressure in lying, sitting, and standing positions helps assess for orthostatic hypotension. 2. Orthostatic hypotension can cause fainting episodes when changing positions. 3. Lying, sitting, and standing readings provide a comprehensive evaluation of blood pressure changes. 4. It helps in identifying if there is a significant drop in blood pressure from lying to standing. 5. This approach aligns with best practices in diagnosing syncope and fainting episodes. Summary of Other Choices: A. Taking blood pressure in arms and thighs is not relevant to assessing orthostatic changes. B. Only taking blood pressure in a lying position does not provide a complete evaluation of potential orthostatic issues. D. Averaging lying and sitting positions may miss important changes when transitioning to a standing position.
Question 3 of 5
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
Correct Answer: D
Rationale: The correct answer is D because as individuals age, there is a natural decline in elastin production and a reduction in subcutaneous fat, leading to thin, lax, and dry skin. Increased vascularity (choice A) would not cause the described skin changes. Increased sweat and sebaceous glands (choice B) typically occur during puberty, not in older adults. An increase in elastin and a decrease in subcutaneous fat (choice C) would not result in the specific skin characteristics mentioned. Therefore, choice D is the most appropriate explanation for the observed skin changes in the elderly man.
Question 4 of 5
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
Correct Answer: D
Rationale: Step-by-step rationale: 1. A papule is a solid, elevated lesion less than 1 cm in diameter, fitting the description. 2. A bulla is a large vesicle greater than 1 cm, not fitting the size criteria in the question. 3. A wheal is a raised, erythematous, edematous papule or plaque, not solid as described. 4. A nodule is a solid, raised lesion larger than 1 cm, not fitting the size criteria in the question. In summary, the correct answer is D (Papule) because it accurately describes the size and characteristics of the lesion in question, while the other options do not match the given description.
Question 5 of 5
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
Correct Answer: B
Rationale: The correct answer is B: Pearly gray and slightly concave. The tympanic membrane should appear pearly gray because it is composed of thin tissue. It should also appear slightly concave due to the shape and position within the ear. This indicates normal and healthy appearance. Incorrect choices: A: Light pink with a slight bulge - The tympanic membrane should not be pink, as it may indicate inflammation. A bulge could suggest fluid behind the membrane. C: Pulled in at the base of the cone of light - This could indicate negative pressure in the middle ear. D: Whitish with a small fleck of light in the superior portion - A whitish appearance may suggest infection or scarring, and a small fleck of light is not a typical finding.