ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
Correct Answer: A
Rationale: Orthostatic blood pressure measurements (lying, sitting, and standing) are recommended for patients experiencing dizziness, especially those on antihypertensive medications.
Question 2 of 5
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, 'I buy obie get spirding and take my train.' What is the best description of this patient's problem?
Correct Answer: D
Rationale: In Wernicke's aphasia, speech is fluent but incomprehensible with word substitutions and made-up words. Patients often have a strong urge to speak but their speech lacks meaningful content.
Question 3 of 5
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
Correct Answer: B
Rationale: With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.
Question 4 of 5
Which of the following is an example of a sign?
Correct Answer: B
Rationale: Signs are objective findings observed or measured during the physical exam, like a temperature of 102° F.
Question 5 of 5
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: A stronger percussion stroke is needed for obese or muscular individuals.