ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:
Correct Answer: A
Rationale: The correct answer is A: Auricle. The auricle is the visible part of the outer ear that consists of movable cartilage and skin. When administering eardrops, pulling the auricle down and back helps straighten the ear canal for proper medication delivery. The other choices are incorrect because: B: Concha is the concave bowl-shaped depression in the outer ear, C: Outer meatus is the ear canal, and D: Mastoid process is a bony prominence behind the ear.
Question 2 of 5
While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be:
Correct Answer: D
Rationale: Correct Answer - D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." Rationale: 1. Prolonged bottle use can lead to tooth decay due to exposure to sugars in milk or formula. 2. The constant sucking can also cause ear infections by pushing bacteria into the Eustachian tubes. 3. It is important for the nurse to educate the mother on these risks to promote the child's health. Summary of Other Choices: A: Incorrect. Encouraging the mother that bottles make good pacifiers does not address the potential health risks associated with prolonged bottle use. B: Incorrect. While it's true that bottle use may be better for teeth than thumb-sucking, it still poses risks for tooth decay and ear infections. C: Incorrect. The contents of the bottle do not negate the risks associated with prolonged bottle use.
Question 3 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 4 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 5 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.