ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 9
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 2 of 9
Which of these would be formulated by a nurse using diagnostic reasoning?
Correct Answer: C
Rationale: Diagnostic reasoning involves formulating a diagnostic hypothesis based on collected data.
Question 3 of 9
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
Correct Answer: C
Rationale: Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
Question 4 of 9
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 5 of 9
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
Correct Answer: B
Rationale: According to JNC 7 guidelines, prehypertension is defined as systolic readings of 120-139 mm Hg or diastolic readings of 80-89 mm Hg.
Question 6 of 9
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
Correct Answer: B
Rationale: With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.
Question 7 of 9
The nurse is assessing a patient for signs of anemia. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: Pale conjunctivae are a common sign of anemia due to decreased red blood cell count.
Question 8 of 9
Which of the following best describes subjective information?
Correct Answer: B
Rationale: Subjective information is based on the patient's personal experience, such as feeling short of breath.
Question 9 of 9
A 50-year-old woman presents with a history of sudden-onset leg pain and swelling. She has a recent history of prolonged immobility due to a recent surgery. What is the most likely diagnosis?
Correct Answer: A
Rationale: Sudden-onset leg pain, swelling, and a history of recent immobility are consistent with deep vein thrombosis (DVT).