ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. You are concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate to order to initially evaluate for this condition?
Correct Answer: C
Rationale: The correct answer is C: Ankle–brachial index (ABI). ABI is a non-invasive test used to assess peripheral vascular disease by comparing blood pressure in the ankle with blood pressure in the arm. In this case, the patient's risk factors (smoking, hypertension) make him susceptible to PVD. Venogram (A) involves injecting contrast dye into a vein to visualize blood flow, which is invasive and not typically used as an initial test. CT scan (B) is useful for imaging but not specific for PVD evaluation. PET scan (D) is used for detecting metabolic activity and is not a standard test for PVD. Therefore, C is the most appropriate initial test for evaluating PVD in this patient.
Question 2 of 5
The nurse is assessing the adaptation of the client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
Correct Answer: D
Rationale: The correct answer is D because consistently using adaptive equipment in dressing shows successful adaptation to changes in functional status after a stroke. This indicates the client's acceptance of their limitations and willingness to use tools that enable independence. Choice A is incorrect as anger towards family is not a positive sign of adaptation. Choice B suggests emotional distress, which is not indicative of successful adaptation. Choice C indicates difficulty with using modified utensils, which is a sign of struggle rather than successful adaptation.
Question 3 of 5
What is the best way for the nurse to assess for clubbing of the fingers?
Correct Answer: B
Rationale: The correct answer is B - Check the angle of the nail bed. Clubbing is characterized by an increased angle (>180 degrees) between the nail bed and the skin. This is best assessed by looking at the nail bed directly. Inspecting for white spots (A), assessing for swelling in the fingertips (C), and observing the color of the nail beds (D) are not specific or accurate indicators of clubbing. Checking the angle of the nail bed is the most direct and reliable method to assess for clubbing of the fingers.
Question 4 of 5
During a musculoskeletal assessment, the nurse observes swelling and redness over a joint. What is the nurse's next action?
Correct Answer: A
Rationale: The correct answer is A: Assess the range of motion of the joint. This is the next action because swelling and redness over a joint can indicate inflammation or injury, which may affect the joint's mobility. Assessing the range of motion will help determine the extent of the issue and guide further interventions. Applying heat (B) may worsen inflammation, documenting as normal (C) is inappropriate given the abnormal findings, and referring for further evaluation (D) can be considered after assessing the range of motion to provide more specific information to the healthcare provider.
Question 5 of 5
During a cardiac assessment, the nurse hears an S3 heart sound. What does this finding suggest?
Correct Answer: C
Rationale: The presence of an S3 heart sound typically indicates heart failure. This occurs due to rapid filling of the ventricles during early diastole, indicating volume overload. This sound is commonly heard in patients with heart failure, reflecting decreased cardiac function. In contrast, option A is incorrect as an S3 is not a normal finding in young adults. Option B, mitral valve stenosis, would present with an opening snap and a diastolic murmur, not an S3 sound. Option D, aortic regurgitation, is associated with a diastolic murmur and bounding pulses, not an S3 heart sound.