ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
When assessing a patient's pulse, the nurse should also notice which of these characteristics?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Force of pulse indicates strength, reflecting cardiac output. 2. It is crucial to assess force to identify abnormalities like weak or bounding pulses. 3. Force helps in diagnosing conditions like heart failure or shock. 4. Pallor, capillary refill, and timing do not directly relate to pulse strength. Summary: A: Force is correct as it reflects cardiac output. B: Pallor is incorrect as it pertains to skin color. C: Capillary refill time is incorrect as it assesses peripheral perfusion. D: Timing in the cardiac cycle is incorrect as it focuses on heart rhythm.
Question 2 of 5
The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's:
Correct Answer: B
Rationale: The correct answer is B: Circulatory status. A thorough skin assessment is important as the skin provides valuable information on blood flow, oxygenation, and perfusion. Changes in skin color, temperature, and integrity can indicate circulatory issues like poor perfusion or compromised circulation. Understanding the circulatory status is crucial for identifying potential health problems and providing appropriate interventions. The other choices (A, C, D) are incorrect as they do not directly correlate with the primary purpose of a skin assessment, which is to evaluate the health of the circulatory system.
Question 3 of 5
A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:
Correct Answer: D
Rationale: The correct answer is D: Trichotillomania; her child probably has a habit of absentmindedly twirling her hair. Trichotillomania is a psychological disorder characterized by the urge to pull out one's hair. In this case, the irregularly shaped patches with broken-off, stublike hair suggest hair pulling rather than a medical condition like folliculitis (A), traumatic alopecia (B), or tinea capitis (C). Folliculitis is a bacterial infection of hair follicles, not related to hair pulling. Traumatic alopecia is hair loss due to physical damage, not consistent with the described symptoms. Tinea capitis is a fungal infection causing hair loss and is not typically associated with broken-off, stublike hair. Trichotillomania is the most likely explanation given the presentation of the child's hair condition.
Question 4 of 5
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?
Correct Answer: B
Rationale: The correct answer is B: Rubella can damage the infant's organ of Corti, which will impair hearing. Rubella virus can cross the placenta and infect the developing fetus, leading to congenital rubella syndrome. This syndrome can cause damage to various organs including the organ of Corti in the inner ear, leading to hearing impairment. This occurs mainly when the infection happens during the first trimester when the organ systems are developing. Incorrect choices: A: Rubella may affect the mother's hearing but not the infant's - This is incorrect as rubella can indeed affect the infant's hearing through congenital rubella syndrome. C: Rubella is only dangerous to the infant in the second trimester of pregnancy - This is incorrect as rubella can harm the infant's hearing in the first trimester as well. D: Rubella can impair the development of CN VIII and thus affect hearing - While rubella can affect hearing, it primarily does so by damaging the organ of Corti
Question 5 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.