ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
Which of the following represents metrorrhagia?
Correct Answer: D
Rationale: Metrorrhagia is defined as bleeding between periods. This is the correct answer as it specifically describes the irregular bleeding pattern associated with metrorrhagia. Choice A refers to the duration between menses, not the timing of bleeding. Choice B relates to the volume of blood, not the timing. Choice C describes infrequent, not irregular, bleeding. Thus, D is the correct choice as it accurately represents metrorrhagia.
Question 2 of 5
Which of the following conditions would produce a hyperresonant percussion note?
Correct Answer: A
Rationale: The correct answer is A: Large pneumothorax. A hyperresonant percussion note indicates excessive air in the chest cavity, leading to increased resonance. In a large pneumothorax, air fills the pleural space, causing the affected lung to collapse and creating a hyperresonant sound upon percussion. Lobar pneumonia (B) typically produces dullness due to consolidation of lung tissue. Pleural effusion (C) results in dullness as well, caused by fluid accumulation in the pleural space. Empyema (D) refers to pus in the pleural space, causing dullness rather than hyperresonance.
Question 3 of 5
The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl's mental status?
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential regression in the girl's social development, preferring to play with younger children. This behavior may suggest difficulty in forming age-appropriate relationships or social skills, which could be concerning in the context of her parents' divorce. Choice A may indicate attachment issues, but it is common for young children to cling to their primary caregiver in stressful situations. Choice B describes a common emotional response to stress but does not necessarily indicate a mental health concern. Choice C is a typical behavior for a 5-year-old and does not raise immediate concerns about her mental status.
Question 4 of 5
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, 'I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!' Which of these responses by the nurse uses empathy?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Response C acknowledges the mother's feelings without judgment, showing understanding and empathy. 2. It validates her emotions by acknowledging the difficulty she is facing. 3. It does not assume or imply any specific emotion, allowing the mother to express herself freely. 4. Responses A and B are close but do not fully capture the depth of empathy displayed in response C. 5. Response D lacks empathy as it focuses more on agreement rather than truly understanding and validating the mother's emotions.
Question 5 of 5
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
Correct Answer: B
Rationale: The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.