ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Correct Answer: A
Rationale: Step 1: The phase I Korotkoff sounds mark the systolic blood pressure (SBP). In this case, they begin at 200 mm Hg. Step 2: The phase V Korotkoff sounds mark the diastolic blood pressure (DBP). In this case, they disappear at 92 mm Hg. Step 3: Therefore, the blood pressure reading is recorded as SBP/DBP. So, the correct recording for this patient would be 200/92 mm Hg. Summary: Choice A is correct as it accurately reflects the SBP and DBP values observed during auscultation. Choices B, C, and D are incorrect because they either include additional or incorrect values for SBP and DBP.
Question 2 of 5
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and 'stuck on' his skin. Which is the best prediction?
Correct Answer: D
Rationale: The correct answer is D: Seborrheic keratoses, which do not become cancerous. Seborrheic keratoses are benign skin growths that are typically greasy, dark, and have a 'stuck on' appearance. They are not cancerous and do not pose a risk of developing into skin cancer. This is important to reassure the patient and alleviate their concerns. A: Senile lentigines are also known as age spots and are benign pigmented spots that do not typically become cancerous. B: Actinic keratoses are precancerous lesions that can develop into squamous cell carcinoma if left untreated. C: Acrochordons, also known as skin tags, are benign growths and not precursors to squamous cell carcinoma. In summary, the other choices are incorrect because they either refer to benign conditions that do not become cancerous (A and C) or precancerous lesions that can progress to skin cancer (
Question 3 of 5
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Cerumen, also known as earwax, serves to protect the ear canal by trapping dust and debris, preventing infections, and lubricating the skin. Its composition helps maintain the pH balance in the ear, preventing bacterial growth. Therefore, the statement that "the purpose of cerumen is to protect and lubricate the ear" is correct. Summary of Incorrect Choices: A: Sticky honey-colored cerumen is not necessarily a sign of infection. Cerumen can vary in color and consistency. B: The presence of cerumen does not solely indicate poor hygiene. It is a natural substance produced by the body. D: While cerumen can affect sound conduction if impacted, it is not necessary for transmitting sound through the auditory canal. Sound waves travel through the eardrum and middle ear to the cochlea.
Question 4 of 5
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:
Correct Answer: A
Rationale: The correct answer is A because infants at 7 months typically turn their head to localize sound. This is a normal auditory milestone indicating the infant's ability to hear and respond to auditory stimuli. Turning the head shows awareness and localization of the sound source. Choices B, C, and D are incorrect as they do not reflect the typical auditory response expected from a 7-month-old. Choice B suggests no response, which would be concerning for hearing impairment. Choice C refers to a startle reflex, which is not the expected response to auditory stimuli at this age. Choice D describes a behavior more indicative of focused attention rather than auditory localization.
Question 5 of 5
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:
Correct Answer: D
Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important because chronic lung disease can lead to mouth breathing, causing dryness in the mouth. Dry mouth can increase the risk of oral health issues and affect overall well-being. A: "Do you use a fluoride supplement?" is not directly related to the patient's history of hypertension and chronic lung disease. B: "Have you had tonsillitis in the last year?" is not as relevant to the patient's current conditions as dryness in the mouth. C: "At what age did you get your first tooth?" is not pertinent to the patient's current health status and medical history.