ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
Correct Answer: C
Rationale: The correct answer is C because kyphosis and flexion in the knees and hips are common age-related changes in older adults. Kyphosis is the forward curvature of the spine, and flexion in the knees and hips can occur due to joint stiffness and muscle weakness. These changes are considered normal in older adults. Option A is incorrect because an increase in body weight is not necessarily normal with aging. Option B is incorrect as additional fat deposits on specific body parts may not necessarily be considered normal. Option D is incorrect because a change in overall body proportion with a longer trunk and shorter extremities is not a typical age-related change.
Question 2 of 5
The nurse is counting an infant's respirations. Which technique is correct?
Correct Answer: B
Rationale: The correct technique for counting an infant's respirations is to watch the abdomen for movement. This is because infants are obligate nasal breathers, so abdominal movement is a more accurate indicator of their breathing pattern. Watching the chest rise and fall (choice A) may not accurately reflect the infant's respiratory rate. Placing a hand across the infant's chest (choice C) may interfere with their breathing and is not recommended. Using a stethoscope to listen to breath sounds (choice D) is not necessary for counting respirations in infants.
Question 3 of 5
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin?
Correct Answer: C
Rationale: The correct answer is C, ashen, gray, or dull. In a black patient with impending shock, the skin often appears ashen or gray due to poor perfusion. This is a result of decreased blood flow and oxygen to the skin, indicating a serious condition. Choice A, ruddy blue, is incorrect as it suggests cyanosis, which is more common in Caucasians. Generalized pallor, choice B, is unlikely in a black patient due to the natural skin pigmentation. Patchy areas of pallor, choice D, are less indicative of impending shock compared to a more uniform ashen or gray appearance.
Question 4 of 5
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: Lyme disease. The bull's eye rash, also known as erythema migrans, is a classic symptom of Lyme disease, caused by the bacterium Borrelia burgdorferi transmitted through tick bites. This distinctive rash pattern is a key diagnostic feature. Rubeola (A) presents with a different rash pattern and symptoms. Allergy to mosquito bites (C) typically results in localized redness and swelling, not a bull's eye rash. Rocky Mountain spotted fever (D) may present with a rash, but it typically does not have the characteristic bull's eye appearance seen in Lyme disease.
Question 5 of 5
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: A
Rationale: The correct answer is A: "Does your baby seem to startle with loud noises?" This question is relevant because exposure to aspirin during pregnancy can potentially lead to hearing loss in the infant. Aspirin is known to cause ototoxicity, affecting the auditory nerve and leading to hearing problems. Therefore, asking about the baby's response to loud noises can help identify any potential hearing issues related to the aspirin exposure during pregnancy. Choices B, C, and D are incorrect because they focus on ear-related issues, such as surgeries, drainage, and infections. While these are valid concerns, they are not directly related to the potential hearing loss caused by aspirin exposure during pregnancy. Hence, these options are less relevant in this context compared to the correct answer, which directly addresses the possible consequence of aspirin intake during pregnancy on the infant's hearing.