ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:
Correct Answer: A
Rationale: The correct answer is A: Acquired immunodeficiency syndrome (AIDS). The dark red confluent macule on the hard palate is known as Kaposi sarcoma, a common manifestation of AIDS. This lesion can be the first visible sign of AIDS in patients with a history of intravenous drug abuse. It is important for the nurse to recognize this early sign to facilitate prompt diagnosis and treatment. Measles (choice B) typically presents with a widespread rash, not a localized lesion on the hard palate. Leukemia (choice C) may present with oral manifestations, but a dark red macule on the hard palate is not a typical finding. Carcinoma (choice D) refers to cancer, which may present differently in the oral cavity compared to Kaposi sarcoma.
Question 2 of 5
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
Correct Answer: C
Rationale: The correct answer is C: Tuberculosis. The key clues in the patient's history are rust-colored sputum, low-grade fevers, and night sweats, which are classic symptoms of tuberculosis. Rust-colored sputum is indicative of blood in the sputum, a common finding in pulmonary tuberculosis. Low-grade fevers and night sweats are also typical symptoms of tuberculosis due to the body's immune response to the infection. Bronchitis (A) typically presents with cough and mucus production without the specific symptoms described. Pneumonia (B) can present with productive cough and fever, but rust-colored sputum and night sweats are less common. Pulmonary edema (D) usually presents with symptoms like shortness of breath and pink frothy sputum, not rust-colored sputum and night sweats.
Question 3 of 5
A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? The presence of benign breast disease:
Correct Answer: A
Rationale: The correct answer is A. Benign breast disease can make breasts feel lumpy or tender, which can make it harder to perform breast exams. This is due to the presence of noncancerous changes in breast tissue. Choices B, C, and D are incorrect because benign breast disease does not frequently turn into cancer, is not easily reduced with hormone replacement therapy, and can be diagnosed at any age, not just before childbearing age.
Question 4 of 5
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: Elevated pressure related to heart failure. The finding of jugular venous pulsations 5 cm above the sternal angle when the head of the bed is elevated 45 degrees is indicative of elevated central venous pressure, which is commonly seen in patients with heart failure. This is known as the hepatojugular reflux test, where pressure is transmitted back to the jugular veins due to increased right atrial pressure in heart failure. This finding suggests impaired cardiac function leading to fluid overload and congestion in the venous system. Choices A, B, and C are incorrect because they do not explain the specific pathophysiological mechanism associated with the patient's presentation.
Question 5 of 5
When assessing a child's lung sounds, the nurse hears loud, low-pitched tones. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider this finding normal for a child. Loud, low-pitched lung sounds in children are often attributed to their thin chest walls and clear airways. Step 1: Understand that children's lung sounds can be louder and lower-pitched compared to adults due to their anatomy. Step 2: Recognize that this finding is typically normal in children and does not require further investigation. Summary: Options B, C, and D are incorrect as they are unnecessary and may lead to unnecessary procedures or testing when the finding is normal in children.