ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
When performing a physical exam on an infant, the nurse should:
Correct Answer: C
Rationale: Rationale for choice C: Starting with less distressing areas such as the abdomen is recommended when performing a physical exam on an infant. This approach helps build rapport and trust with the infant, allowing them to feel more comfortable during the exam. It also helps prevent unnecessary stress and agitation, leading to a smoother and more successful examination process. By starting with non-invasive areas, the nurse can gradually progress to more sensitive areas without causing undue distress to the infant. Summary of why other choices are incorrect: A: Conducting the exam in a head-to-toe manner may overwhelm the infant and increase stress levels. B: Beginning with invasive procedures like ear examination can cause discomfort and lead to resistance from the infant. D: Waiting for the infant to wake up before starting the exam is not practical as the nurse should take advantage of the infant's calm state during sleep to perform the exam efficiently.
Question 2 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 3 of 5
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
Correct Answer: C
Rationale: The correct answer is C because a newborn's skin is more permeable than that of an adult, making them more susceptible to fluid loss. This is due to the thinner and less developed skin barrier in newborns, which can lead to increased transepidermal water loss. A: Subcutaneous fat deposits being high in the newborn would actually help with insulation and temperature regulation, reducing the risk of fluid loss. B: Sebaceous glands being overproductive in the newborn would contribute to skin lubrication and protection, not fluid loss. D: The presence of vernix caseosa helps to protect the infant's skin and prevent excessive fluid loss, so an increase in vernix caseosa would not lead to fluid loss.
Question 4 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 5 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.