ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Correct Answer: B
Rationale: The correct answer is B because giving feedback and reassurance during the examination is appropriate for a 4-year-old child. This approach helps to build trust, reduce anxiety, and make the child feel more comfortable. Providing reassurance also helps the child understand what is happening and promotes cooperation during the examination. Explanation for other choices: A: Explaining procedures in detail may overwhelm and increase anxiety in a 4-year-old child. C: Avoiding asking the child to remove clothing may hinder a thorough examination and compromise the child's health. D: Performing a head-to-toe examination starting with the ears may not be developmentally appropriate or engaging for a 4-year-old child.
Question 2 of 5
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
Correct Answer: B
Rationale: The correct answer is B because auscultating an apical rate for 1 minute allows for a more accurate assessment of the infant's heart rate, which can vary. This method helps detect any abnormalities, such as sinus arrhythmia commonly seen in infants. Auscultating the apical rate is more accurate than palpating the radial pulse in infants due to their small size and delicate nature. Assessing blood pressure in infants requires specialized equipment, not just a stethoscope with a large diaphragm piece. Observing the chest for respiratory rate is important but does not provide a full assessment of vital signs.
Question 3 of 5
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
Correct Answer: D
Rationale: The correct answer is D: Importance of sunscreen and avoiding direct sunlight. Rationale: 1. Oral hypoglycemic agents can increase sensitivity to sunlight, leading to sunburn or skin damage. 2. Diabetic patients are at higher risk of skin complications, so protecting the skin from sunlight is crucial. 3. Sun exposure can also affect blood sugar levels, potentially causing fluctuations in glucose levels. 4. Use of sunscreen and avoiding direct sunlight can help prevent skin issues and maintain overall health for a diabetic patient. Summary: A: Increased possibility of bruising - Not directly related to diabetes or oral hypoglycemic agents. B: Skin sensitivity as a result of exposure to salt water - Not a common concern for diabetic patients on oral hypoglycemic agents. C: Lack of availability of glucose-monitoring supplies - Important but not directly related to the side effects of oral hypoglycemic agents.
Question 4 of 5
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?
Correct Answer: D
Rationale: The correct answer is D because the description matches the characteristic rash of measles, known as Koplik spots. These spots typically appear before the onset of the classic maculopapular rash that starts behind the ears and spreads to the face and body. Measles is highly contagious, and Koplik spots are a hallmark sign. A: Pink, papular rash on the face and neck - This description does not match the presentation of measles. B: Pruritic vesicles over her trunk and neck - This description is more indicative of conditions like chickenpox, not measles. C: Hyperpigmentation on the chest, abdomen, and back of the arms - This description does not align with the symptoms of measles.
Question 5 of 5
The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?
Correct Answer: A
Rationale: Step 1: Air conduction is the normal pathway for hearing, where sound waves travel through the outer ear canal, eardrum, middle ear bones, and into the cochlea in the inner ear. Step 2: Vibrations of the bones in the skull (choice B) refer to bone conduction, not air conduction. Step 3: Amplitude of sound (choice C) determines loudness, not pitch. Step 4: Loss of air conduction (choice D) is called conductive hearing loss, but this is not the true statement about air conduction.