ATI RN
Assessing Vital Signs Questions
Question 1 of 5
A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is:
Correct Answer: C
Rationale: The correct answer is C because it accurately explains that the top number (systolic pressure) reflects the pressure in the arteries when the heart contracts. This is important information as it indicates the maximum pressure exerted on the arteries during a heartbeat. The bottom number represents diastolic pressure, which is the pressure in the arteries when the heart is at rest between beats. This information helps assess overall cardiovascular health. Choice A is incorrect because just stating the numbers are normal does not provide any educational value to the patient. Choice B is incorrect as it inaccurately describes the diastolic pressure. Choice D is incorrect as it simplifies the explanation and focuses on the wrong aspect of blood pressure.
Question 2 of 5
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:
Correct Answer: D
Rationale: The correct answer is D: Excess blood in the dilated superficial capillaries. Hyperemia is characterized by an increase in blood flow to a specific area, leading to redness. This is caused by vasodilation of superficial capillaries, allowing more blood to flow through the area. Choices A and C are incorrect because decreased amounts of bilirubin in the blood and decreased perfusion do not lead to hyperemia. Choice B is incorrect because excess blood in the underlying blood vessels does not directly cause the redness seen in hyperemia.
Question 3 of 5
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
Correct Answer: B
Rationale: The correct answer is B because the yellow color of the sclera extending up to the iris is indicative of true jaundice, known as scleral icterus. This occurs when there is an excess of bilirubin in the blood, causing yellow discoloration. Yellow patches in the outer sclera (choice A) may be due to other causes like pinguecula. Skin appearing yellow under low light (choice C) may be due to lighting conditions. Yellow deposits on palms and soles (choice D) are seen in conditions like carotenemia, not jaundice.
Question 4 of 5
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Asking about the relationship between ear pain and discharge is crucial in assessing for a perforated eardrum. Pain and discharge are common symptoms, indicating a possible perforation. This question helps to determine the presence and severity of these symptoms, aiding in diagnosis and treatment planning. Summary of Incorrect Choices: A: Asking about ringing or crackling in the ears is not specific to a perforated eardrum. B: Inquiring about the last hearing check does not directly address symptoms related to a perforated eardrum. C: Asking about previous hearing loss is not directly relevant to assessing for a perforated eardrum.
Question 5 of 5
The salivary gland that is the largest and located in the cheek in front of the ear is the _____gland.
Correct Answer: A
Rationale: The correct answer is A: Parotid gland. This gland is the largest salivary gland and is located in the cheek in front of the ear. The parotid gland is responsible for producing the majority of saliva in the mouth. Stensen's gland (choice B) is another name for the parotid gland duct, not the gland itself. Sublingual gland (choice C) is located under the tongue, and submandibular gland (choice D) is located beneath the lower jaw. The location and size of the parotid gland align with the description given in the question, making it the correct choice.