ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Cerumen, also known as earwax, serves to protect the ear canal by trapping dust and debris, preventing infections, and lubricating the skin. Its composition helps maintain the pH balance in the ear, preventing bacterial growth. Therefore, the statement that "the purpose of cerumen is to protect and lubricate the ear" is correct. Summary of Incorrect Choices: A: Sticky honey-colored cerumen is not necessarily a sign of infection. Cerumen can vary in color and consistency. B: The presence of cerumen does not solely indicate poor hygiene. It is a natural substance produced by the body. D: While cerumen can affect sound conduction if impacted, it is not necessary for transmitting sound through the auditory canal. Sound waves travel through the eardrum and middle ear to the cochlea.
Question 2 of 5
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:
Correct Answer: D
Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important because chronic lung disease can lead to mouth breathing, causing dryness in the mouth. Dry mouth can increase the risk of oral health issues and affect overall well-being. A: "Do you use a fluoride supplement?" is not directly related to the patient's history of hypertension and chronic lung disease. B: "Have you had tonsillitis in the last year?" is not as relevant to the patient's current conditions as dryness in the mouth. C: "At what age did you get your first tooth?" is not pertinent to the patient's current health status and medical history.
Question 3 of 5
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
Correct Answer: A
Rationale: The correct answer is A because a smooth glossy dorsal surface of the tongue is not a normal finding in adults. This could indicate atrophic glossitis, which may be due to nutritional deficiencies or other health issues. Choice B is incorrect because a thin white coating over the tongue can be a normal variation or may indicate minor issues like oral thrush. Choice C is incorrect as raised papillae on the dorsal surface is a normal finding, especially in smokers or individuals with certain oral health conditions. Choice D is incorrect as visible venous patterns on the ventral surface are also a normal finding and not considered abnormal.
Question 4 of 5
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:
Correct Answer: A
Rationale: The correct answer is A: Dullness. Atelectasis is a condition where there is complete or partial collapse of the lung. When percussing over an area of atelectasis, the sound produced is dull due to the lack of air in the affected lung tissue, which dampens the sound transmission. This is in contrast to normal lung tissue, which produces a resonant sound due to the presence of air. Tympany is a drum-like sound heard over air-filled structures like the stomach, not over atelectatic lung tissue. Hyperresonance is an abnormally loud, low-pitched sound heard in conditions like emphysema, not atelectasis.
Question 5 of 5
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?
Correct Answer: C
Rationale: The correct answer is C because it includes the most relevant nodes for assessing a woman's axillary lymph system. The central, lateral, pectoral, and subscapular nodes are key areas to examine for any abnormalities or signs of inflammation. The central nodes are located in the central axillary line, the lateral nodes are along the upper humerus, the pectoral nodes are near the pectoralis major muscle, and the subscapular nodes are beneath the scapula. These nodes drain lymph from different parts of the breast and upper extremities, making them essential for evaluating the axillary lymph system. The other choices are incorrect because they either do not include all the necessary nodes or include nodes that are less relevant for this specific assessment.