ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
Correct Answer: B
Rationale: The correct answer is B) An increased respiratory rate and a shallower inspiratory phase are expected findings in aging adults. This is because as individuals age, their respiratory muscles weaken and lung elasticity decreases, leading to a shallower breathing pattern and an increased respiratory rate to maintain adequate oxygenation. Option A is incorrect because while blood vessel stiffness may affect blood pressure measurements, it does not directly impact the palpation of the pulse. Option C is incorrect as a decreased pulse pressure typically results from increased arterial stiffness, not changes in both systolic and diastolic pressures. Option D is incorrect because aging does not necessarily make a person more prone to developing a fever; rather, it may affect the body's ability to regulate temperature efficiently. In an educational context, it is essential for nurses and healthcare providers to understand the physiological changes that occur with aging to accurately assess vital signs in older adults. By recognizing expected findings like changes in respiratory rate and depth, healthcare professionals can provide appropriate care and interventions tailored to the needs of this population.
Question 2 of 5
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:
Correct Answer: B
Rationale: Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.
Question 3 of 5
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
Correct Answer: C
Rationale: In the context of a patient with sensorineural hearing loss, it is crucial for the nurse to ask the patient what medications he is currently taking (Option C). This is the correct answer because sensorineural hearing loss is often caused by factors like aging, genetics, or exposure to loud noise, and certain medications can also contribute to hearing impairment. By inquiring about the patient's current medications, the nurse can gather important information to assess potential medication-induced hearing loss and facilitate appropriate interventions or referrals. Option A, speaking loudly, is incorrect as it does not address the underlying cause of sensorineural hearing loss and may not be effective for the patient. Option B, assessing for a middle ear infection, is also incorrect because sensorineural hearing loss typically originates from the inner ear or auditory nerve, not the middle ear. Option D, looking for an obstruction in the external ear, is not relevant for sensorineural hearing loss, which is usually related to damage in the inner ear structures. In an educational context, understanding the underlying causes of sensorineural hearing loss and the importance of medication history in assessing hearing health is essential for nurses to provide comprehensive and individualized care to patients with hearing impairments. This question highlights the significance of a thorough assessment and tailored interventions based on the specific needs of patients with sensorineural hearing loss.
Question 4 of 5
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:
Correct Answer: A
Rationale: An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.
Question 5 of 5
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
Correct Answer: D
Rationale: Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.