ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
Correct Answer: C
Rationale: The correct answer is C. The tympanic method reduces the risk of cross-contamination compared to rectal temperature measurement. This is because the tympanic thermometer does not come into direct contact with mucous membranes or bodily fluids, unlike rectal thermometers. Cross-contamination can occur when pathogens are transmitted between individuals or surfaces. Therefore, using the tympanic method decreases the chances of spreading infections. Choice A is incorrect as tympanic temperature measurement is quicker compared to rectal temperature measurement. Choice B is incorrect as the tympanic method is non-invasive and generally well-tolerated. Choice D is incorrect as the tympanic membrane reflects the temperature of the blood vessels in the temporal artery, not the ophthalmic artery.
Question 2 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 3 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 4 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.
Question 5 of 5
In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?
Correct Answer: D
Rationale: Rationale: In otitis externa, the infection usually involves the outer ear canal and surrounding tissues. Enlarged superficial cervical nodes are a common sign due to the lymphatic drainage in the area. Rhinorrhea (A) is associated with nasal congestion, not ear infections. Periorbital edema (B) is seen in conditions affecting the eyes or surrounding tissues. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa. Ultimately, D is the correct answer as it aligns with the typical presentation of otitis externa.