ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
Correct Answer: D
Rationale: The correct answer is D because as individuals age, there is a natural decline in elastin production and a reduction in subcutaneous fat, leading to thin, lax, and dry skin. Increased vascularity (choice A) would not cause the described skin changes. Increased sweat and sebaceous glands (choice B) typically occur during puberty, not in older adults. An increase in elastin and a decrease in subcutaneous fat (choice C) would not result in the specific skin characteristics mentioned. Therefore, choice D is the most appropriate explanation for the observed skin changes in the elderly man.
Question 2 of 5
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
Correct Answer: B
Rationale: The correct answer is B: Pearly gray and slightly concave. The tympanic membrane should appear pearly gray because it is composed of thin tissue. It should also appear slightly concave due to the shape and position within the ear. This indicates normal and healthy appearance. Incorrect choices: A: Light pink with a slight bulge - The tympanic membrane should not be pink, as it may indicate inflammation. A bulge could suggest fluid behind the membrane. C: Pulled in at the base of the cone of light - This could indicate negative pressure in the middle ear. D: Whitish with a small fleck of light in the superior portion - A whitish appearance may suggest infection or scarring, and a small fleck of light is not a typical finding.
Question 3 of 5
The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?
Correct Answer: A
Rationale: The correct answer is A: High-tone frequency loss. In older adults, age-related hearing loss affects high-tone frequencies first due to changes in the inner ear structures. This is considered a normal age-related change. Increased elasticity of the pinna (B) is not related to aging but rather a congenital or acquired condition. A thin, translucent membrane (C) or a shiny, pink tympanic membrane (D) may indicate issues like infection or inflammation, not normal aging changes in the ear.
Question 4 of 5
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Correct Answer: B
Rationale: The correct technique when using an otoscope to assess the nasal cavity is to avoid touching the nasal septum with the speculum. This is important because the nasal septum is a sensitive area that can be easily irritated or damaged. By avoiding contact with the septum, the nurse can prevent discomfort or potential injury to the patient. Choice A is incorrect because inserting the speculum 3 cm into the vestibule is unnecessary and may cause discomfort to the patient. Choice C is incorrect as displacing the nose can distort the anatomy and make it difficult to assess the nasal cavity accurately. Choice D is incorrect as keeping the speculum tip medial to avoid touching the floor of the nares is not a standard technique and may not provide an optimal view of the nasal cavity.
Question 5 of 5
The nurse is performing an assessment. Which of these findings would cause the greatest concern?
Correct Answer: D
Rationale: The correct answer is D because an ulceration on the side of the tongue with rolled edges could indicate a potential malignancy like oral cancer. This finding is concerning due to its location and characteristics, which warrant further investigation and prompt intervention. Explanation for incorrect choices: A: A painful vesicle inside the cheek for 2 days is likely a benign condition like a canker sore. B: Presence of moist, nontender Stensen's ducts is a normal finding related to salivary gland function. C: Stippled gingival margins that snugly adhere to the teeth indicate healthy gum tissue and proper attachment.