ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
Correct Answer: A
Rationale: The correct answer is A: "Does your baby seem to startle with loud noises?" This question is relevant because exposure to aspirin during pregnancy can potentially lead to hearing loss in the infant. Aspirin is known to cause ototoxicity, affecting the auditory nerve and leading to hearing problems. Therefore, asking about the baby's response to loud noises can help identify any potential hearing issues related to the aspirin exposure during pregnancy. Choices B, C, and D are incorrect because they focus on ear-related issues, such as surgeries, drainage, and infections. While these are valid concerns, they are not directly related to the potential hearing loss caused by aspirin exposure during pregnancy. Hence, these options are less relevant in this context compared to the correct answer, which directly addresses the possible consequence of aspirin intake during pregnancy on the infant's hearing.
Question 2 of 5
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
Correct Answer: C
Rationale: The correct answer is C: "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." Rationale: 1. Black, hairy tongue is a known side effect of prolonged antibiotic use, leading to fungal overgrowth. 2. Antibiotics can disrupt the natural balance of bacteria in the mouth, allowing fungi to overgrow. 3. Fungal infections can manifest as a black, hairy appearance on the tongue. 4. Biopsy is not typically needed for the diagnosis of black, hairy tongue. 5. Overgrowth of hair is not a plausible explanation for this condition. 6. The black, hairy tongue is not caused by the same bacteria the patient had in his lungs. Summary: Choice C is correct as it accurately links the patient's antibiotic use to the fungal infection causing black, hairy tongue. Choices A, B, and D are incorrect as they do not address the specific cause of this condition and provide inaccurate information.
Question 3 of 5
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
Correct Answer: A
Rationale: The correct answer is A, between the scapulae. Tactile fremitus is most intense over areas where there is a solid lung structure close to the chest wall, such as between the scapulae where the main bronchi are located. This proximity allows for better transmission of vibrations generated by vocalization. Choices B, C, and D are incorrect because they do not align with the anatomical locations of solid lung structures. The third intercostal space, midaxillary line, and lower lobes do not provide the necessary proximity to produce intense tactile fremitus.
Question 4 of 5
A woman in her 26th week of pregnancy states that she is 'not really short of breath' but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?
Correct Answer: C
Rationale: The correct answer is C because in the 26th week of pregnancy, it is normal for women to experience an increased awareness of their breathing without actual shortness of breath. This is due to the growing fetus putting pressure on the diaphragm, leading to a sensation of needing to breathe more frequently. The nurse's response should reassure the woman that her experience is normal and not a cause for concern. Choice A is incorrect because the diaphragm does not become fixed during pregnancy, rather it is pushed upward by the growing uterus. Choice B is incorrect because although estrogen levels increase during pregnancy, causing changes in the rib cage, this does not directly lead to difficulty in breathing. Choice D is incorrect because the increased awareness of breathing is not solely due to the increased oxygen demand from the fetus but also from the physical changes in the body due to pregnancy.
Question 5 of 5
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?
Correct Answer: C
Rationale: The correct answer is C: "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" This question is crucial because the location of the rash can provide valuable clues about the potential cause. For example, a rash on the nipple may point towards issues like Paget's disease, while a rash on the areola could suggest eczema or contact dermatitis. On the other hand, a rash on the surrounding skin may indicate a fungal infection or allergic reaction. By identifying the precise location of the rash, the nurse can narrow down the differential diagnosis and develop an appropriate care plan. Summary: A: "Is the rash raised and red?" - This question focuses on the appearance of the rash but does not provide specific information about its location, which is more critical in determining the cause. B: "Does it appear to be cyclic?" - This question is not as directly relevant to identifying the cause of the rash compared to pinpointing its location. D