ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A 68-year-old retired postman presents with dull, intermittent left-sided chest pain over several weeks, occurring after physical activity. The pain radiates to the left jaw and resolves with rest.
Correct Answer: A
Rationale: Rationale: The description of chest pain occurring with physical activity, radiating to the jaw, and relieved by rest is classic for angina pectoris. This pattern suggests myocardial ischemia due to coronary artery disease, common in older individuals. Pericarditis typically presents with sharp, pleuritic chest pain worsened by breathing. Dissecting aortic aneurysm causes severe, tearing chest pain often radiating to the back. Pleural pain is typically sharp and worsens with deep breaths, not related to physical activity.
Question 2 of 5
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
Correct Answer: B
Rationale: The correct answer is B because the woman's verbal statement ("excited about the pregnancy") does not align with her nonverbal behaviors (looking nervously at her hands, sighing loudly). This inconsistency between verbal and nonverbal communication is a key indicator of potential underlying concerns or emotions that the woman may not be openly expressing. Option A can be ruled out because there is no direct indication of nervousness about labor. Option C is incorrect as there is no mention of the husband's feelings in the scenario. Option D is not supported by the information provided; the woman did not express fear of the nurse's response but rather exhibits nonverbal cues that may indicate hidden concerns or anxieties. Thus, option B is the most accurate choice based on the observed mismatch between verbal and nonverbal behaviors.
Question 3 of 5
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to 'warm up' and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Correct Answer: B
Rationale: The correct answer is B. Stopping down to the toddler's level and asking her about the toy she is holding is the best approach because it shows respect for the toddler's interests and allows for engagement on her terms, fostering a sense of trust and comfort. This approach acknowledges the toddler's autonomy and helps build a positive relationship. Option A is incorrect because tickling the toddler may not be appropriate and could potentially lead to discomfort or fear. Option C is incorrect as continuing to ignore the toddler may cause her to feel neglected and hinder the establishment of rapport. Option D is incorrect because it is important for the mother to be present to provide comfort and support during the examination.
Question 4 of 5
The nurse notes a drumlike percussion sound over the abdomen. This indicates:
Correct Answer: B
Rationale: The drumlike percussion sound over the abdomen suggests air-filled areas. This occurs because air in the stomach or intestines resonates when tapped, creating a hollow sound. This finding is consistent with conditions like gastric distention or bowel obstruction. Constipation (A) would not typically produce a drumlike sound. The presence of a tumor (C) or dense organs (D) would not lead to this specific percussion finding.
Question 5 of 5
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
Correct Answer: A
Rationale: The correct answer is A because a tympanic membrane thermometer provides rapid measurements, making it ideal for uncooperative younger children. This is crucial in clinical settings where quick and accurate temperature readings are necessary. Choice B is incorrect as the TMT may not be the most accurate method for newborn infants due to their delicate ear structure. Choice C is incorrect as TMT devices can be relatively expensive. Choice D is incorrect as studies may not strongly support the use of TMT in children under 6 years due to factors like accuracy and reliability.