ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?
Correct Answer: B
Rationale: The correct answer is B: Hypomobility. In otitis media, there is an accumulation of fluid in the middle ear, which can lead to decreased mobility of the tympanic membrane. This can be observed during pneumatic otoscopy when the tympanic membrane does not move normally in response to insufflation. Choices A, C, and D are incorrect. A) A red and bulging tympanic membrane is more indicative of acute otitis media. C) Retraction with landmarks clearly visible is a sign of negative pressure in the middle ear, possibly indicating eustachian tube dysfunction. D) A flat, slightly pulled in at the center, and moves with insufflation is characteristic of a normal tympanic membrane.
Question 2 of 5
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
Correct Answer: C
Rationale: Step 1: Understand the costal angle is the angle formed by the ribcage at the sternum. Step 2: A costal angle of approximately 90 degrees is within the normal range (normal is 90-120 degrees). Step 3: This angle allows for proper expansion of the lungs during breathing. Step 4: Choices A, B, and D are incorrect as they describe conditions or characteristics that are not associated with a normal costal angle. Summary: Option C is correct because a costal angle of approximately 90 degrees is a normal finding in a healthy adult, allowing for proper respiratory function.
Question 3 of 5
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary consolidation. Bronchophony is a finding in which spoken words are heard distinctly and clearly through the stethoscope, indicating increased lung density. This is commonly seen in pulmonary consolidation, where air-filled lung tissue becomes filled with fluid or solid material. This can be caused by conditions such as pneumonia or lung tumors. Assessing for signs of pulmonary consolidation, such as increased tactile fremitus, dullness to percussion, and crackles on auscultation, is crucial. Choices A, B, and D are incorrect because bronchophony is not typically associated with these conditions. Airway obstruction, emphysema, and asthma have different characteristic auscultation findings and are not directly linked to bronchophony.
Question 4 of 5
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
Correct Answer: D
Rationale: Step 1: After menopause, hormonal changes lead to a decrease in estrogen levels. Step 2: Decreased estrogen causes glandular and fat tissue in the breasts to atrophy. Step 3: Atrophy of glandular and fat tissue results in diminished breast size and elasticity. Step 4: Diminished size and elasticity lead to breasts sagging. Step 5: Therefore, option D is correct as it accurately explains the physiological process behind breast sagging after menopause. Summary: Option A is incorrect as breast sagging can occur in women with any breast size. Option B is incorrect as breast sagging is not primarily due to decreased muscle mass. Option C is incorrect as protein intake does not directly prevent breast sagging caused by tissue atrophy.
Question 5 of 5
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?
Correct Answer: C
Rationale: The correct answer is C because BSE (Breast Self-Examination) on a monthly basis helps women become familiar with their breasts, enabling them to detect any abnormal changes early. This empowers women to seek timely medical help if needed, potentially improving outcomes. Choice A is incorrect as having children does not determine the importance of BSE. Choice B is incorrect as the statistic of one in nine women developing breast cancer does not directly relate to the importance of BSE. Choice D is incorrect because while BSE can help in early detection, it is not a guaranteed life-saving measure between mammograms.