ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Which of these specific measurements is the best index of a child's general health?
Correct Answer: B
Rationale: The correct answer is B: Height and weight. These measurements provide important indicators of a child's growth and development, which are key components of overall health. Height and weight measurements can help assess nutritional status, growth patterns, and potential health issues. Vital signs (A) are important for monitoring immediate health status but do not provide a comprehensive view of general health. Head circumference (C) is primarily used in infancy to assess brain development. Chest circumference (D) is not typically used as a general health indicator in children. In summary, height and weight measurements offer a holistic view of a child's health by evaluating growth, nutrition, and overall well-being.
Question 2 of 5
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
Correct Answer: B
Rationale: The correct answer is B because the yellow color of the sclera extending up to the iris is indicative of true jaundice, known as scleral icterus. This occurs when there is an excess of bilirubin in the blood, causing yellow discoloration. Yellow patches in the outer sclera (choice A) may be due to other causes like pinguecula. Skin appearing yellow under low light (choice C) may be due to lighting conditions. Yellow deposits on palms and soles (choice D) are seen in conditions like carotenemia, not jaundice.
Question 3 of 5
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Asking about the relationship between ear pain and discharge is crucial in assessing for a perforated eardrum. Pain and discharge are common symptoms, indicating a possible perforation. This question helps to determine the presence and severity of these symptoms, aiding in diagnosis and treatment planning. Summary of Incorrect Choices: A: Asking about ringing or crackling in the ears is not specific to a perforated eardrum. B: Inquiring about the last hearing check does not directly address symptoms related to a perforated eardrum. C: Asking about previous hearing loss is not directly relevant to assessing for a perforated eardrum.
Question 4 of 5
The salivary gland that is the largest and located in the cheek in front of the ear is the _____gland.
Correct Answer: A
Rationale: The correct answer is A: Parotid gland. This gland is the largest salivary gland and is located in the cheek in front of the ear. The parotid gland is responsible for producing the majority of saliva in the mouth. Stensen's gland (choice B) is another name for the parotid gland duct, not the gland itself. Sublingual gland (choice C) is located under the tongue, and submandibular gland (choice D) is located beneath the lower jaw. The location and size of the parotid gland align with the description given in the question, making it the correct choice.
Question 5 of 5
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: Step-by-step rationale for why Option D is correct: 1. Hormonal changes during pregnancy can lead to increased blood flow to gums, causing them to be swollen and bleed. 2. This condition is known as pregnancy gingivitis and is a common occurrence during pregnancy. 3. The nurse should educate the woman about the link between hormonal changes and gum health. 4. Referring the woman to a dentist is important for further evaluation and management. 5. Option D is the most appropriate response as it addresses the specific issue related to pregnancy and gum health.