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ATI RN · ATI Fundamentals · Vital Signs Health Assessment

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

The nurse is examining a 2-year-old child. What is the best way to begin the assessment?

A. Ask the parent to place the child on the exam table.

B. Have the child remove all clothing before the exam.

C. Allow the child to keep a toy or blanket for comfort.

D. Directly interact with the child, ignoring the parent.

Expert Explanatory Rationale

Correct Answer: Allow the child to keep a toy or blanket for comfort.

Question 2 of 5

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?

A. Assessing the skin for cyanosis and swelling

B. Assessing the oral mucosa for generalized erythema

C. Palpating the skin for edema and increased warmth

D. Palpating for tenderness and local areas of ecchymosis

Expert Explanatory Rationale

Correct Answer: Palpating the skin for edema and increased warmth

Question 3 of 5

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?

A. Refer the patient to a throat specialist.

B. No response is needed; this appearance is normal for the tonsils.

C. Continue with the assessment, looking for any other abnormal findings.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

Expert Explanatory Rationale

Correct Answer: No response is needed; this appearance is normal for the tonsils.

Question 4 of 5

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

A. Count the patient's respirations.

B. Bilaterally percuss the thorax, noting any differences in percussion tones.

C. Call for a chest X-ray study and wait for the results before beginning an assessment.

D. Inspect the thorax for any new masses and bleeding associated with respirations.

Expert Explanatory Rationale

Correct Answer: Bilaterally percuss the thorax, noting any differences in percussion tones.

Question 5 of 5

When assessing the apical pulse, where should the nurse place the stethoscope?

A. At the second intercostal space, left sternal border.

B. At the fifth intercostal space, midclavicular line.

C. At the fourth intercostal space, midaxillary line.

D. At the sixth intercostal space, anterior axillary line.

Expert Explanatory Rationale

Correct Answer: At the fifth intercostal space, midclavicular line.

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