ATI RN
ATI Vital Signs Assessment Questions
Question 1 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 2 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.
Question 3 of 5
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
Correct Answer: A
Rationale: The correct answer is A: When the bronchial tree is obstructed. Decreased breath sounds are expected in situations where airflow is obstructed, leading to diminished sound transmission. When there is an obstruction in the bronchial tree, such as in asthma or bronchitis, breath sounds become decreased due to the restricted airflow. The other choices are incorrect because: B: When adventitious sounds are present - Adventitious sounds like crackles or wheezes indicate abnormal lung sounds but do not necessarily result in decreased breath sounds. C: In conjunction with whispered pectoriloquy - Whispered pectoriloquy is a finding where whispering is heard clearly through the stethoscope, indicating lung consolidation rather than decreased breath sounds. D: In conditions of consolidation, such as pneumonia - Consolidation leads to increased breath sounds due to the denser lung tissue, not decreased breath sounds.
Question 4 of 5
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
Correct Answer: B
Rationale: The correct answer is B: Ipsilateral axillary. When a patient reports a breast infection, it is likely localized to one breast. The lymphatic drainage from the breast primarily flows to the ipsilateral axillary lymph nodes. Therefore, the nurse should expect to find enlargement in the ipsilateral axillary nodes as they are the first line of defense in filtering out any infection or inflammation from the affected breast. Choices A, C, and D are incorrect because nonspecific node enlargement would not be specific to a breast infection, contralateral axillary nodes would not be affected by a unilateral breast infection, and inguinal and cervical nodes are not typically involved in breast infections.
Question 5 of 5
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
Correct Answer: C
Rationale: Rationale: C is correct because determining if the inversion is a recent change is crucial to assess for potential underlying causes like breast cancer. A: Incorrect because nipple inversion can be unilateral. B: Incorrect, unilateral inversion doesn't always indicate a serious condition. D: Incorrect, nipple inversion alone warrants further investigation regardless of a palpable mass.