ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. In patients with chronic respiratory conditions like emphysema and bronchitis, clubbing of the nails can be seen due to chronic hypoxia. This is characterized by a bulbous enlargement of the fingertips and nails curving over the fingertips. This finding is related to chronic oxygen deprivation, indicating long-standing respiratory issues. Incorrect choices: A: Anasarca - Generalized edema, not typically associated with emphysema and bronchitis. B: Scleroderma - Connective tissue disorder causing skin thickening, not directly related to respiratory conditions. C: Pedal erythema - Redness of the feet, not a common finding in emphysema and bronchitis.
Question 2 of 5
In performing a voice test to assess hearing, which of these actions would the nurse perform?
Correct Answer: B
Rationale: The correct answer is B because whispering random numbers and letters and asking the patient to repeat them is a common method used in voice tests to assess hearing ability. This test evaluates both the patient's ability to hear and understand speech at a normal conversation level. Whispering ensures that the patient relies solely on their auditory ability without any visual cues. A: Shielding the lips would hinder the patient's ability to hear the nurse clearly, making it an inappropriate action for a voice test. C: Asking the patient to occlude outside noise by placing a finger in the ear is not part of a standard voice test procedure and does not assess hearing directly. D: Standing 4 feet away doesn't provide a standardized or controlled environment for a voice test and may not accurately evaluate the patient's hearing ability.
Question 3 of 5
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B because when a patient experiences a nosebleed, sitting up with the head tilted forward and pinching the nose helps to apply pressure to the bleeding area, promoting clotting and stopping the bleeding. This position also prevents blood from flowing down the throat, which can cause choking or swallowing blood. Placing a cold compress while sitting up (choice A) can help constrict blood vessels, but the key action of applying pressure by pinching the nose is missing. Allowing bleeding to stop on its own (choice C) without taking any immediate action could lead to excessive blood loss. Lying on the back with the head tilted back (choice D) is not recommended as it can cause blood to flow back into the throat and potentially lead to aspiration.
Question 4 of 5
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: C
Rationale: The correct answer is C because by 18 months of age, it is normal for a toddler to have around 12 teeth, which usually include incisors, canines, and first molars. At this age, the child is still in the process of teething, and most children have about half of their primary teeth by 18 months. Choices A, B, and D are incorrect because asking the mother about her own teeth does not address the toddler's situation, stating that all 20 deciduous teeth should be erupted by age 4 is not accurate as teething varies, and mentioning 16 teeth by age 2-4 does not specifically address the situation at 18 months.
Question 5 of 5
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _____ comparison.
Correct Answer: A
Rationale: The correct method is side-to-side comparison. This allows for a systematic approach by ensuring all areas are examined equally. Moving side-to-side helps to maintain consistency and accuracy in assessing lung sounds. Top-to-bottom, posterior-to-anterior, and interspace-by-interspace methods may lead to missed areas or confusion in tracking progress. Side-to-side comparison is the most effective technique for thorough auscultation.