ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?
Correct Answer: C
Rationale: Rationale: C is correct because in newborns, the normal tympanic membrane can appear thick and opaque due to a thinner eardrum and presence of amniotic fluid remnants. A: Immobility of the drum is not normal. B: An injected membrane indicates a hemorrhage, not necessarily infection. D: The appearance of the membrane differs in newborns due to their unique anatomy.
Question 2 of 5
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
Correct Answer: C
Rationale: Correct Answer: C. Allergic rhinitis Rationale: The patient's symptoms of itching, sneezing, and clear rhinorrhea are classic signs of allergic rhinitis. The pale and swollen turbinates also support this diagnosis, as they are common findings in allergic rhinitis due to inflammation from allergens. Incorrect Choices: A: Nasal polyps - Nasal polyps typically present with nasal congestion, loss of smell, and may be associated with asthma. They are not commonly associated with clear rhinorrhea and itching. B: Acute sinusitis - Acute sinusitis is characterized by facial pain, pressure, purulent nasal discharge, and fever. The absence of these symptoms makes acute sinusitis less likely. D: Acute rhinitis - Acute rhinitis, or the common cold, usually presents with thick nasal discharge, sore throat, and low-grade fever. The clear rhinorrhea and itching in this patient are more
Question 3 of 5
The nurse is auscultating the chest in an adult. Which technique is correct?
Correct Answer: C
Rationale: The correct technique for auscultating the chest in an adult is to firmly hold the diaphragm of the stethoscope against the chest. This allows for optimal transmission of sound and better detection of abnormal lung or heart sounds. Instructing the patient to take deep, rapid breaths (Choice A) may interfere with accurate auscultation. Breathing through the nose (Choice B) does not impact the technique. Lightly holding the bell of the stethoscope (Choice D) may lead to poor sound transmission and decreased sensitivity in detecting faint sounds.
Question 4 of 5
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
Correct Answer: B
Rationale: The correct answer is B: The location of most breast tumors. This is because statistically, the upper outer quadrant of the breast is where the majority of breast tumors are found. This area is more glandular and has more breast tissue, making it a common site for tumors to develop. It is important to focus on this area during a breast examination to detect any abnormalities early. A: The largest quadrant of the breast - This is not the reason why examining the upper outer quadrant is important for detecting breast tumors. C: Where most of the suspensory ligaments attach - While true, this is not the primary reason for focusing on the upper outer quadrant during a breast examination. D: More prone to injury and calcifications than other locations in the breast - While calcifications can occur in this area, it is not the primary reason for its importance in detecting breast tumors.
Question 5 of 5
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Asymmetry of breast size is not uncommon, as breasts are typically not perfectly symmetrical. 2. The nurse should verify that the change is not new to rule out any concerning underlying issues. 3. This step is important to ensure the asymmetry is not a new development, which could indicate a potential problem. 4. By verifying that the change is not new, the nurse can provide appropriate care or further evaluation if needed. Summary of why the other choices are incorrect: A: Breasts do not need to always be symmetric; natural variation exists. B: Breastfeeding can cause temporary asymmetry, but the nurse should still verify the change is not new. D: Asymmetry is not necessarily indicative of inflammation or growth; verifying the change's timeline is crucial.