ATI RN
Vital Signs Assessment Quizlet Questions
Question 1 of 5
A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?
Correct Answer: D
Rationale: In the context of a patient with chronic obstructive pulmonary disease (COPD), the correct observation during assessment would be an anteroposterior-to-transverse diameter ratio of 1:1 (Option D). This finding is indicative of a barrel chest, a common characteristic in COPD patients due to chronic air trapping and hyperinflation of the lungs. This physical change occurs as a compensatory mechanism to accommodate the increased residual volume in the lungs. Option A, unequal chest expansion, is typically seen in conditions like pneumothorax or pleural effusion, not specifically in COPD. Option B, increased tactile fremitus, is associated with conditions like pneumonia or lung consolidation, not a typical finding in COPD. Option C, atrophied neck and trapezius muscles, is more commonly observed in conditions causing muscle wasting or denervation, not directly related to COPD. Educationally, understanding these specific physical assessment findings in COPD patients is crucial for nurses to provide comprehensive care, monitor disease progression, and intervene appropriately. Recognizing the significance of a 1:1 anteroposterior-to-transverse diameter ratio can aid in early detection of complications and guide treatment decisions in COPD management.
Question 2 of 5
The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?
Correct Answer: D
Rationale: The correct answer is D) The atria contract toward the end of diastole and push the remaining blood into the ventricles. Atrial kick refers to the additional boost of blood into the ventricles that occurs when the atria contract just before ventricular systole. This action helps to optimize ventricular filling, increasing the amount of blood pumped out to the body. Option A is incorrect because the atria do not contract during systole; they contract during diastole. Option B is incorrect as palpitations are sensations of rapid or irregular heartbeats, not related to atrial kick. Option C is also incorrect as it describes the pressure exerted against the atria, not the action of the atria contracting to push blood into the ventricles. Understanding atrial kick is crucial in comprehending cardiac physiology and its impact on cardiac output. Atrial kick accounts for approximately 15-20% of ventricular filling, highlighting its significance in maintaining adequate cardiac function. Educating healthcare professionals on this concept enhances their ability to assess and interpret vital signs accurately, leading to improved patient care outcomes.
Question 3 of 5
Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?
Correct Answer: C
Rationale: In a cardiac assessment of a 4-year-old child, the nurse would expect to notice a murmur at the second left intercostal space when the child is in a supine position (Option C) due to the presence of innocent murmurs common in children. This is the correct answer because innocent murmurs are frequently heard in pediatric populations and are typically benign, requiring no treatment or intervention. Option A (S3 when sitting up) is incorrect because S3 is not a common finding in children and is more indicative of heart failure in adults. Option B (Persistent tachycardia above 150 beats per minute) is incorrect as a heart rate above 150 bpm is abnormal in a 4-year-old child. Option D (Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line) is incorrect because a palpable apical impulse in this location is more typical of an adult and not a child. Educationally, it is important for healthcare professionals to understand the normal variations in pediatric vital signs and assessments to differentiate between benign findings and those that require further investigation or intervention. Recognizing innocent murmurs in children helps prevent unnecessary anxiety for parents and unnecessary testing or treatment for the child.
Question 4 of 5
Induration along the ventral surface of the penis suggests which of the following?
Correct Answer: A
Rationale: Urethral stricture may cause induration of the ventral surface of the penis. It more rarely represents a local carcinoma. A testicular carcinoma would be much more likely to occur in the scrotum. Peyronie's disease often causes induration on the dorsal proximal penis, and epidermoid cysts are benign findings on the scrotum.
Question 5 of 5
A patient complains of leg pain that wakes him at night. He states that he 'has been having problems' with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed 'a sore' on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:
Correct Answer: B
Rationale: The correct answer is B) Problems related to arterial insufficiency. In this scenario, the patient's symptoms suggest a possible peripheral arterial disease. The leg pain that is worse at night and improves when dangling the legs is indicative of decreased blood flow to the lower extremities when elevated, a classic symptom of arterial insufficiency. The presence of a sore on the inner aspect of the right ankle further supports this diagnosis as it could be an ulcer due to poor circulation. Option A) Pain related to lymphatic abnormalities is incorrect as the symptoms described are more consistent with arterial rather than lymphatic issues. Option C) Problems related to venous insufficiency typically present with symptoms like edema, varicose veins, and pain that worsens when standing for long periods, which are not evident in this case. Option D) Pain related to musculoskeletal abnormalities does not fit the patient's symptoms of worsening pain with leg elevation and improvement with dangling, along with the presence of an ulcer. Understanding how to differentiate between arterial and venous insufficiency based on patient history is crucial for nurses in assessing and managing patients with potential circulatory issues. Recognizing these subtle differences can lead to timely interventions and prevent further complications.