ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. In children, the disappearance of phase V Korotkoff sounds is commonly used to determine diastolic blood pressure. 2. Phase V represents the complete cessation of sound, indicating the return of blood flow to normal. 3. This method is preferred over phase IV sounds due to the potential for overestimating diastolic pressure. 4. Utilizing phase V ensures a more accurate diastolic reading in children. Summary of other choices: A: Blood pressure guidelines for children are based on height, not age. B: Phase I Korotkoff sounds indicate the initial appearance of faint tapping sounds, not phase II. C: Doppler devices are not routinely recommended for blood pressure measurements in children.
Question 2 of 5
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
Correct Answer: C
Rationale: The correct answer is C, severe dehydration. Decreased skin turgor is a clinical sign of dehydration due to fluid loss, causing the skin to lose its elasticity. In contrast, severe obesity (choice A) would not typically result in decreased skin turgor. Childhood growth spurts (choice B) do not directly affect skin turgor. Connective tissue disorders like scleroderma (choice D) may affect skin quality, but decreased skin turgor specifically indicates dehydration. Therefore, choice C is the most likely condition associated with decreased skin turgor.
Question 3 of 5
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides a physiological explanation for the child's frequent ear infections. The eustachian tube in young children is indeed shorter and wider than in adults, making it easier for infections to develop. This is due to the anatomy of the child's ear, not necessarily indicating a more severe underlying issue. Choice A is incorrect as it implies there must be something else wrong, which is not necessarily the case. Choice B is incorrect as checking the immune system may not be the first step in addressing frequent ear infections. Choice C is incorrect as cerumen is not directly related to the development of ear infections in this context.
Question 4 of 5
The primary purpose of the ciliated mucous membrane in the nose is to:
Correct Answer: B
Rationale: The correct answer is B: Filter out dust and bacteria. The ciliated mucous membrane in the nose acts as a physical barrier to trap and remove harmful particles like dust and bacteria from the inhaled air. Here's the rationale: 1. The cilia trap particles: The cilia in the mucous membrane sweep back and forth, capturing dust and bacteria in the mucus. 2. Mucus removes particles: The sticky mucus traps the particles, preventing them from entering the respiratory system. 3. Prevents infections: By filtering out harmful particles, the mucous membrane helps protect the respiratory system from infections. 4. Other choices are incorrect: A is incorrect as the primary function is not to warm the air. C is incorrect as it focuses on coarse particles only. D is incorrect as it does not specifically address the filtration function of the mucous membrane.
Question 5 of 5
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:
Correct Answer: C
Rationale: The correct answer is C: Bruising on the buccal mucosa or gums. This is because bruising in the oral cavity can be indicative of physical abuse in children. The nurse should look for signs of trauma that may not be easily visible on other parts of the body. Bruising on the buccal mucosa or gums could be a result of forceful feeding, hitting, or physical abuse. A: Swollen, red tonsils - Typically not associated with child abuse unless there are other signs of trauma. B: Ulcerations on the hard palate - Unlikely to be a common sign of physical abuse in a child. D: Small yellow papules along the hard palate - Not typically associated with physical abuse; more likely related to other oral health issues. In summary, bruising on the buccal mucosa or gums is the most relevant sign to look for in this scenario as it could indicate possible child abuse.