ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
Correct Answer: B
Rationale: The correct answer is B: Pearly gray and slightly concave. The tympanic membrane should appear pearly gray because it is composed of thin tissue. It should also appear slightly concave due to the shape and position within the ear. This indicates normal and healthy appearance. Incorrect choices: A: Light pink with a slight bulge - The tympanic membrane should not be pink, as it may indicate inflammation. A bulge could suggest fluid behind the membrane. C: Pulled in at the base of the cone of light - This could indicate negative pressure in the middle ear. D: Whitish with a small fleck of light in the superior portion - A whitish appearance may suggest infection or scarring, and a small fleck of light is not a typical finding.
Question 2 of 5
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Correct Answer: B
Rationale: The correct technique when using an otoscope to assess the nasal cavity is to avoid touching the nasal septum with the speculum. This is important because the nasal septum is a sensitive area that can be easily irritated or damaged. By avoiding contact with the septum, the nurse can prevent discomfort or potential injury to the patient. Choice A is incorrect because inserting the speculum 3 cm into the vestibule is unnecessary and may cause discomfort to the patient. Choice C is incorrect as displacing the nose can distort the anatomy and make it difficult to assess the nasal cavity accurately. Choice D is incorrect as keeping the speculum tip medial to avoid touching the floor of the nares is not a standard technique and may not provide an optimal view of the nasal cavity.
Question 3 of 5
The nurse is performing an assessment. Which of these findings would cause the greatest concern?
Correct Answer: D
Rationale: The correct answer is D because an ulceration on the side of the tongue with rolled edges could indicate a potential malignancy like oral cancer. This finding is concerning due to its location and characteristics, which warrant further investigation and prompt intervention. Explanation for incorrect choices: A: A painful vesicle inside the cheek for 2 days is likely a benign condition like a canker sore. B: Presence of moist, nontender Stensen's ducts is a normal finding related to salivary gland function. C: Stippled gingival margins that snugly adhere to the teeth indicate healthy gum tissue and proper attachment.
Question 4 of 5
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
Correct Answer: A
Rationale: The correct answer is A: When the bronchial tree is obstructed. Decreased breath sounds are expected in situations where airflow is obstructed, leading to diminished sound transmission. When there is an obstruction in the bronchial tree, such as in asthma or bronchitis, breath sounds become decreased due to the restricted airflow. The other choices are incorrect because: B: When adventitious sounds are present - Adventitious sounds like crackles or wheezes indicate abnormal lung sounds but do not necessarily result in decreased breath sounds. C: In conjunction with whispered pectoriloquy - Whispered pectoriloquy is a finding where whispering is heard clearly through the stethoscope, indicating lung consolidation rather than decreased breath sounds. D: In conditions of consolidation, such as pneumonia - Consolidation leads to increased breath sounds due to the denser lung tissue, not decreased breath sounds.
Question 5 of 5
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
Correct Answer: B
Rationale: The correct answer is B: Ipsilateral axillary. When a patient reports a breast infection, it is likely localized to one breast. The lymphatic drainage from the breast primarily flows to the ipsilateral axillary lymph nodes. Therefore, the nurse should expect to find enlargement in the ipsilateral axillary nodes as they are the first line of defense in filtering out any infection or inflammation from the affected breast. Choices A, C, and D are incorrect because nonspecific node enlargement would not be specific to a breast infection, contralateral axillary nodes would not be affected by a unilateral breast infection, and inguinal and cervical nodes are not typically involved in breast infections.