ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
Correct Answer: A
Rationale: Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
Question 2 of 5
A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?
Correct Answer: A
Rationale: Chest pain that increases with breathing is typically related to the musculoskeletal system, such as costochondritis or pleuritic pain.
Question 3 of 5
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 5
After striking their head on a tree while falling from a ladder, the patient is admitted unconscious with nonreactive pupils. Which intervention would be the most dangerous for the client?
Correct Answer: D
Rationale: A lumbar puncture in the presence of increased ICP can cause brain herniation.
Question 5 of 5
The components of the health history include all of the following except which one?
Correct Answer: B
Rationale: Thorax and lungs are part of the physical examination, not the health history.