ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?
Correct Answer: A
Rationale: Step 1: Air conduction is the normal pathway for hearing, where sound waves travel through the outer ear canal, eardrum, middle ear bones, and into the cochlea in the inner ear. Step 2: Vibrations of the bones in the skull (choice B) refer to bone conduction, not air conduction. Step 3: Amplitude of sound (choice C) determines loudness, not pitch. Step 4: Loss of air conduction (choice D) is called conductive hearing loss, but this is not the true statement about air conduction.
Question 2 of 5
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
Correct Answer: A
Rationale: Step 1: Dry mucosa and deep vertical fissures in the tongue are classic signs of dehydration. Step 2: Dehydration can result from prolonged nausea and vomiting leading to fluid loss. Step 3: Lack of fluid intake contributes to dry mucosa and fissures in the tongue. Step 4: Therefore, the correct answer is A: Dehydration. Other choices are incorrect as they do not explain the specific physical signs observed in the patient.
Question 3 of 5
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale: The correct answer is C: Maxillary sinusitis. The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and pain in the cheeks and teeth on one side with palpation are indicative of maxillary sinusitis. The maxillary sinuses are located in the cheekbones, and inflammation can lead to these specific symptoms. Posterior epistaxis (A) refers to bleeding from the back of the nose, which is not consistent with the patient's symptoms. Frontal sinusitis (B) would present with symptoms in the forehead region, not in the cheeks and teeth. Nasal polyps (D) are growths in the nasal passages and usually do not cause the specific symptoms described in the case.
Question 4 of 5
When inspecting the anterior chest of an adult, the nurse should include which assessment?
Correct Answer: D
Rationale: The correct answer is D, examining the shape and configuration of the chest wall. This assessment helps identify any abnormalities such as barrel chest or pectus excavatum. Diaphragmatic excursion (A) is assessed at the posterior chest. Symmetric chest expansion (B) is relevant for assessing lung function, not specifically the anterior chest. Presence of breath sounds (C) is important but does not specifically pertain to the anterior chest assessment.
Question 5 of 5
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? The nurse should tell her that:
Correct Answer: C
Rationale: The correct answer is C because cyclic breast changes are common due to hormonal fluctuations during the monthly menstrual cycle. This is a normal physiological process where breasts may feel different at different times of the month. It is important for the nurse to reassure the woman that these changes are normal. Choice A is incorrect as it states that continual changes in breasts are unusual, which is not accurate for nonpregnant women. Choice B is incorrect as it focuses on stress as the cause of breast changes, which is not the primary reason in this case. Choice D is incorrect as it suggests that breast changes only occur during pregnancy, which is not true as hormonal fluctuations during the menstrual cycle can also cause changes in breasts.