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ATI RN · ATI Fundamentals · Assess Vital Signs Rationale

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

A. Sticky honey-colored cerumen is a sign of infection.

B. The presence of cerumen is indicative of poor hygiene.

C. The purpose of cerumen is to protect and lubricate the ear.

D. Cerumen is necessary for transmitting sound through the auditory canal.

Expert Explanatory Rationale

Correct Answer: The purpose of cerumen is to protect and lubricate the ear.

Question 2 of 5

M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse?

A. "Tell me what prompted that question."

B. "I will ask your physician to discuss this matter with you."

C. "Let's take each day as it comes."

D. "I think you should discuss that with your family."

Expert Explanatory Rationale

Correct Answer: "Tell me what prompted that question."

Question 3 of 5

A 35-year-old man presents with a complaint of dizziness and fainting. His blood pressure is found to be 100/60 mm Hg when he is standing up. What is the most likely cause of his symptoms?

A. Postural hypotension

B. Arrhythmia

C. Anemia

D. Hyperthyroidism

Expert Explanatory Rationale

Correct Answer: Postural hypotension

Question 4 of 5

During a cardiovascular assessment, the nurse auscultates a soft, blowing sound over the left upper sternal border. What does this finding suggest?

A. Normal heart sounds.

B. Heart murmur.

C. Heart failure.

D. Aortic stenosis.

Expert Explanatory Rationale

Correct Answer: Heart murmur.

Question 5 of 5

Which of the following assessment findings is most consistent with chronic venous insufficiency?

A. Pale, cool skin.

B. Brown discoloration around the ankles.

C. Diminished pulses.

D. Intermittent claudication.

Expert Explanatory Rationale

Correct Answer: Brown discoloration around the ankles.

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