ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
Correct Answer: B
Rationale: The correct answer is B because the yellow color of the sclera extending up to the iris is indicative of true jaundice, known as scleral icterus. This occurs when there is an excess of bilirubin in the blood, causing yellow discoloration. Yellow patches in the outer sclera (choice A) may be due to other causes like pinguecula. Skin appearing yellow under low light (choice C) may be due to lighting conditions. Yellow deposits on palms and soles (choice D) are seen in conditions like carotenemia, not jaundice.
Question 2 of 5
The salivary gland that is the largest and located in the cheek in front of the ear is the _____gland.
Correct Answer: A
Rationale: The correct answer is A: Parotid gland. This gland is the largest salivary gland and is located in the cheek in front of the ear. The parotid gland is responsible for producing the majority of saliva in the mouth. Stensen's gland (choice B) is another name for the parotid gland duct, not the gland itself. Sublingual gland (choice C) is located under the tongue, and submandibular gland (choice D) is located beneath the lower jaw. The location and size of the parotid gland align with the description given in the question, making it the correct choice.
Question 3 of 5
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: Step-by-step rationale for why Option D is correct: 1. Hormonal changes during pregnancy can lead to increased blood flow to gums, causing them to be swollen and bleed. 2. This condition is known as pregnancy gingivitis and is a common occurrence during pregnancy. 3. The nurse should educate the woman about the link between hormonal changes and gum health. 4. Referring the woman to a dentist is important for further evaluation and management. 5. Option D is the most appropriate response as it addresses the specific issue related to pregnancy and gum health.
Question 4 of 5
The primary muscles of respiration include the:
Correct Answer: A
Rationale: The diaphragm and intercostal muscles are the primary muscles of respiration. The diaphragm contracts during inhalation, increasing the volume of the thoracic cavity, while the intercostal muscles assist in expanding the ribcage. This creates negative pressure in the lungs, allowing air to flow in. The other choices, sternomastoids and scaleni, trapezii and rectus abdominis, and external obliques and pectoralis major, are not directly involved in the inhalation and exhalation process of respiration, making them incorrect choices.
Question 5 of 5
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
Correct Answer: A
Rationale: The correct answer is A: Asthma. The assessment findings described are classic signs of an asthma exacerbation. Tachypnea, prolonged expiration, intercostal retractions, and expiratory wheezes are all indicative of narrowed airways and difficulty breathing, which are characteristic of asthma. The use of accessory neck muscles indicates increased effort to breathe. Decreased breath sounds are due to air trapping in the lungs. In contrast, choices B, C, and D do not typically present with the combination of symptoms described. Atelectasis usually presents with decreased breath sounds and crackles. Lobar pneumonia typically presents with fever, productive cough, and focal chest signs. Heart failure presents with bilateral crackles, edema, and jugular venous distension.