ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
Correct Answer: B
Rationale: The correct answer is B: Enlarged and tender inguinal nodes. Infections in the foot can lead to regional lymphadenopathy, causing enlargement and tenderness in the inguinal nodes closest to the affected area. This is a common sign of local infection. A: Hard and fixed cervical nodes are not typical findings for an infection in the foot. Cervical nodes are located in the neck and would not be directly affected by a foot infection. C: Bilateral enlargement of the popliteal nodes is not a common finding in foot infections. Popliteal nodes are located behind the knees and would not be directly involved in a foot infection. D: Pelletlike nodes in the supraclavicular region are not expected findings for a foot infection. Supraclavicular nodes are located in the neck and are not typically involved in a localized foot infection.
Question 2 of 5
A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?
Correct Answer: B
Rationale: The correct answer is B: Small amplitude, weak. In congestive heart failure, the heart's ability to pump effectively is compromised, leading to reduced cardiac output. As a result, the pulse would be small in amplitude and weak. This is due to the heart's inability to generate enough force to produce a strong pulse. Choices A, C, and D are incorrect because in congestive heart failure, the pulse is not large amplitude, forceful, normal, or bigeminal. It is important to recognize the specific characteristics of the pulse in different medical conditions to make accurate assessments.
Question 3 of 5
You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Tachypnea (rapid breathing). This is a cue related to the patient's pain because pain can lead to increased respiratory rate as a physiological response. The body's natural reaction to pain is to increase breathing to provide more oxygen to tissues. Therefore, tachypnea is a relevant cue to assess pain levels. A: Normal skin turgor is not directly related to pain assessment. Skin turgor is typically assessed to evaluate hydration status. B: Normal S1, S2 heart sounds are not directly related to pain assessment. Heart sounds are assessed to evaluate cardiac function. C: Glowing skin is not a typical cue related to pain assessment. Glowing skin may be associated with overall health and well-being but is not directly related to pain.
Question 4 of 5
Mark each of the following statements as therapeutic or nontherapeutic. c. "Dr. Daniels knows what he is talking about. Just follow his recommendations."
Correct Answer: B
Rationale: The correct answer is B: Nontherapeutic. This statement is nontherapeutic because it implies a lack of autonomy and empowerment for the individual seeking help. It suggests blindly following advice without considering personal preferences or values. This can hinder the therapeutic process by diminishing the client's ability to actively participate in decision-making and problem-solving. Therapeutic communication focuses on collaboration, empowerment, and respect for the client's autonomy. Choices A, C, and D are left blank as they do not provide a suitable rationale for the given question.
Question 5 of 5
Scoliosis can be classified as structural or functional. Which one of the following is NOT a characteristic of structural scoliosis?
Correct Answer: B
Rationale: The correct answer is B: It is reversible. Structural scoliosis involves irreversible changes in the spine's alignment, such as rotation and curvature due to factors like abnormal growth or spinal deformities. Reversibility is not a characteristic of structural scoliosis. A: Most cases are idiopathic - This is a characteristic of structural scoliosis as idiopathic scoliosis is the most common type. C: Subtype of structural scoliosis includes idiopathic - This supports the characteristic of idiopathic scoliosis within the structural category. D: Subtypes of structural scoliosis include congenital or acquired - This is correct as structural scoliosis can be caused by congenital abnormalities or acquired conditions, supporting the definition of structural scoliosis.