ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:
Correct Answer: A
Rationale: An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.
Question 2 of 5
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of:
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
The nurse knows that auscultation of fine crackles would most likely be noticed in:
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
Correct Answer: A
Rationale: The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk), may be expressed from the breasts.
Question 5 of 5
The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.