ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The salivary gland that is the largest and located in the cheek in front of the ear is the _____gland.
Correct Answer: A
Rationale: The correct answer is A: Parotid gland. This gland is the largest salivary gland and is located in the cheek in front of the ear. The parotid gland is responsible for producing the majority of saliva in the mouth. Stensen's gland (choice B) is another name for the parotid gland duct, not the gland itself. Sublingual gland (choice C) is located under the tongue, and submandibular gland (choice D) is located beneath the lower jaw. The location and size of the parotid gland align with the description given in the question, making it the correct choice.
Question 2 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 3 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 4 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.
Question 5 of 5
Which of these statements describes the closure of the valves in a normal cardiac cycle?
Correct Answer: C
Rationale: The correct answer is C because in a normal cardiac cycle, the closure of the valves follows a specific sequence. The mitral valve closes slightly before the tricuspid valve due to the ventricular pressure changes. The closure of the mitral valve marks the beginning of systole, while the tricuspid valve closes shortly after. Choices A and B are incorrect as they do not accurately describe the sequence of valve closure. Choice D is incorrect because the tricuspid and pulmonic valves do not close at the same time in a normal cardiac cycle.