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: The correct answer is B) Increased vascularity in the upper respiratory tract as a result of pregnancy. During pregnancy, hormonal changes lead to an increase in blood volume and circulation, causing the blood vessels in the upper respiratory tract to become more dilated and fragile. This increased vascularity can result in common pregnancy symptoms such as nasal congestion, nosebleeds, and nasal stuffiness. Option A) A problem with the patient's coagulation system is incorrect because nosebleeds during pregnancy are typically due to increased vascularity rather than a coagulation disorder. Option C) Increased susceptibility to colds and nasal irritation is not the primary reason for nosebleeds in pregnancy. While pregnant women may be more prone to respiratory infections, the increased vascularity is the main factor contributing to nosebleeds. Option D) Inappropriate use of nasal sprays is not the cause in this scenario unless the woman is using nasal sprays excessively or inappropriately. However, the most likely reason for her nosebleeds is the physiological changes related to pregnancy. Educationally, understanding the physiological changes that occur during pregnancy and their impact on various body systems, including the respiratory system, is crucial for healthcare providers to provide appropriate care and support to pregnant individuals. Recognizing common symptoms like nosebleeds as a result of increased vascularity can help nurses and other healthcare professionals address these issues effectively and reassure patients that they are experiencing normal pregnancy-related changes.
Question 3 of 5
The nurse knows that auscultation of fine crackles would most likely be noticed in:
Correct Answer: C
Rationale: In this scenario, option C, "The immediate newborn period," is the correct answer. Fine crackles, also known as fine rales, are the result of fluid in the small airways or alveoli. In the immediate newborn period, it is common for newborns to have transient tachypnea and retained lung fluid, which can lead to the presence of fine crackles upon auscultation. Option A, a healthy 5-year-old child, is incorrect because fine crackles are not typically heard in healthy children without underlying respiratory conditions. Option B, a pregnant woman, is also incorrect as fine crackles are not a common finding in pregnant women unless there are pre-existing respiratory issues. Option D, association with a pneumothorax, is incorrect as crackles associated with a pneumothorax would typically be described as pleural friction rubs rather than fine crackles. From an educational standpoint, understanding the significance of fine crackles in different clinical contexts is crucial for accurate assessment and diagnosis. It highlights the importance of recognizing age-specific variations in normal and abnormal findings during physical assessments, particularly in vulnerable populations like newborns. This knowledge helps nurses provide appropriate care and interventions based on their assessment findings.
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: In this scenario, the missing information from the documentation is the size of the lump (Option C). Understanding the size of a breast lump is crucial in assessing its significance and determining the appropriate course of action. Size helps in categorizing the lump as small, medium, or large, which is essential in clinical decision-making. Option A (Shape of the lump) and Option B (Consistency of the lump) are important aspects of a thorough breast examination, but in this case, the key missing detail is the size of the lump. Knowing whether the lump is solitary or multiple (Option D) is also relevant but is secondary to determining the size, which is more critical for clinical assessment and follow-up. Educationally, emphasizing the importance of documenting the size of a breast lump helps students and healthcare providers understand the significance of this detail in the overall assessment of breast health. It highlights the need for comprehensive documentation to ensure accurate communication and appropriate patient care.