ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Asking about the relationship between ear pain and discharge is crucial in assessing for a perforated eardrum. Pain and discharge are common symptoms, indicating a possible perforation. This question helps to determine the presence and severity of these symptoms, aiding in diagnosis and treatment planning. Summary of Incorrect Choices: A: Asking about ringing or crackling in the ears is not specific to a perforated eardrum. B: Inquiring about the last hearing check does not directly address symptoms related to a perforated eardrum. C: Asking about previous hearing loss is not directly relevant to assessing for a perforated eardrum.
Question 2 of 5
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: Step-by-step rationale for why Option D is correct: 1. Hormonal changes during pregnancy can lead to increased blood flow to gums, causing them to be swollen and bleed. 2. This condition is known as pregnancy gingivitis and is a common occurrence during pregnancy. 3. The nurse should educate the woman about the link between hormonal changes and gum health. 4. Referring the woman to a dentist is important for further evaluation and management. 5. Option D is the most appropriate response as it addresses the specific issue related to pregnancy and gum health.
Question 3 of 5
The primary muscles of respiration include the:
Correct Answer: A
Rationale: The diaphragm and intercostal muscles are the primary muscles of respiration. The diaphragm contracts during inhalation, increasing the volume of the thoracic cavity, while the intercostal muscles assist in expanding the ribcage. This creates negative pressure in the lungs, allowing air to flow in. The other choices, sternomastoids and scaleni, trapezii and rectus abdominis, and external obliques and pectoralis major, are not directly involved in the inhalation and exhalation process of respiration, making them incorrect choices.
Question 4 of 5
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
Correct Answer: A
Rationale: The correct answer is A: Asthma. The assessment findings described are classic signs of an asthma exacerbation. Tachypnea, prolonged expiration, intercostal retractions, and expiratory wheezes are all indicative of narrowed airways and difficulty breathing, which are characteristic of asthma. The use of accessory neck muscles indicates increased effort to breathe. Decreased breath sounds are due to air trapping in the lungs. In contrast, choices B, C, and D do not typically present with the combination of symptoms described. Atelectasis usually presents with decreased breath sounds and crackles. Lobar pneumonia typically presents with fever, productive cough, and focal chest signs. Heart failure presents with bilateral crackles, edema, and jugular venous distension.
Question 5 of 5
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:
Correct Answer: B
Rationale: Rationale: Option B is correct because the nurse should gather more information to assess the patient's pain properly. This response shows active listening and empathy, facilitating a comprehensive evaluation. Option A is incorrect as it dismisses the patient's concern and provides inaccurate information about breast cancer. Option C is incorrect as it shifts the focus to the nurse's experience rather than addressing the patient's current situation. Option D is incorrect because while breast pain can be benign, assuming it is always benign without further assessment can lead to missed diagnoses.