ATI RN
Assessing Vital Signs ATI Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: D
Rationale: The correct response is D: "She is just starting to salivate and hasn't learned to swallow the saliva." At 3 months old, infants often start drooling due to increased salivation as their salivary glands develop. This response acknowledges normal infant development and provides an explanation for the observed behavior. Choice A (You're right, drooling is usually a sign of the first tooth) is incorrect because while drooling can be associated with teething, it is not the primary reason for drooling in a 3-month-old. Choice B (It would be unusual for a 3-month-old to be getting her first tooth) is incorrect because teething can start as early as 3 months, although it is more common around 6 months. Choice C (This could be the sign of a problem with the salivary glands) is incorrect as it jumps to a less likely conclusion of a salivary gland issue without considering the normal developmental process of salivation in infants
Question 5 of 5
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
Correct Answer: C
Rationale: The correct answer is C: "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." Rationale: 1. Black, hairy tongue is a known side effect of prolonged antibiotic use, leading to fungal overgrowth. 2. Antibiotics can disrupt the natural balance of bacteria in the mouth, allowing fungi to overgrow. 3. Fungal infections can manifest as a black, hairy appearance on the tongue. 4. Biopsy is not typically needed for the diagnosis of black, hairy tongue. 5. Overgrowth of hair is not a plausible explanation for this condition. 6. The black, hairy tongue is not caused by the same bacteria the patient had in his lungs. Summary: Choice C is correct as it accurately links the patient's antibiotic use to the fungal infection causing black, hairy tongue. Choices A, B, and D are incorrect as they do not address the specific cause of this condition and provide inaccurate information.