ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A patient has had a 'terrible itch' for several months that he has been continuously scratching. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: Lichenification. Lichenification is a skin condition characterized by thickening and hardening of the skin due to chronic irritation or scratching. In this case, the patient's continuous scratching of the itch has led to lichenification. This is evident by the rough and leathery texture of the skin upon examination. A: A keloid is an overgrowth of scar tissue that can occur after a wound heals, not typically associated with chronic scratching. B: A fissure is a small, painful crack in the skin that can occur due to dryness or trauma, not a result of continuous scratching. C: Keratosis refers to various skin conditions characterized by thickening of the skin, but it is not specifically associated with chronic scratching like lichenification. In summary, lichenification is the most likely finding in this scenario due to the chronic scratching leading to skin thickening and hardening.
Question 2 of 5
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):
Correct Answer: B
Rationale: The correct answer is B: Acute otitis media. In this case, the bright red tympanic membrane and the absence of the light reflex suggest inflammation and infection of the middle ear, which are characteristic of acute otitis media. The child's symptoms of pulling on his ear also support this diagnosis. A: Fungal infection typically presents with white patches and not necessarily redness or absence of light reflex. C: Perforation of the eardrum would show a visible hole in the tympanic membrane. D: Cholesteatoma is a noncancerous growth that would present differently on otoscopic examination.
Question 3 of 5
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
Correct Answer: B
Rationale: The correct answer is B: Firm pressure. When palpating sinus areas, normal findings should elicit a sensation of firm pressure. This is because the sinuses are air-filled cavities that should not cause pain or discomfort when palpated. Sensing firm pressure indicates normal sinus function. Choices A, C, and D are incorrect because normal sinus palpation should not result in no sensation, pain during palpation, or pain sensation behind the eyes. These sensations could indicate sinus inflammation, infection, or other abnormalities that should be further assessed.
Question 4 of 5
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
Correct Answer: D
Rationale: The correct response is D. Using nasal medications can irritate the nasal lining, leading to rebound swelling, which causes the medication to become less effective over time. This explains why the woman's nasal spray is not working as well as before. It is important for the nurse to address this issue to prevent worsening of symptoms. Choice A is incorrect as not all over-the-counter nasal sprays carry a risk of addiction. Choice B is not the best response as switching brands may not address the underlying issue of rebound swelling. Choice C is incorrect as it does not address the potential problem of rebound swelling caused by the nasal spray.
Question 5 of 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
Correct Answer: B
Rationale: The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management. Incorrect choices: A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold. C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent. D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.