ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloration in the woman's face, nail beds, lips, and oral mucosa suggests carbon monoxide poisoning due to the formation of carboxyhemoglobin. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red appearance. Polycythemia would not cause this specific color change. Carotenemia results in a yellow-orange skin tint, not cherry-red. Uremia typically presents with symptoms related to kidney dysfunction, such as fluid retention and electrolyte imbalances, not skin discoloration.
Question 2 of 5
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B because when a patient experiences a nosebleed, sitting up with the head tilted forward and pinching the nose helps to apply pressure to the bleeding area, promoting clotting and stopping the bleeding. This position also prevents blood from flowing down the throat, which can cause choking or swallowing blood. Placing a cold compress while sitting up (choice A) can help constrict blood vessels, but the key action of applying pressure by pinching the nose is missing. Allowing bleeding to stop on its own (choice C) without taking any immediate action could lead to excessive blood loss. Lying on the back with the head tilted back (choice D) is not recommended as it can cause blood to flow back into the throat and potentially lead to aspiration.
Question 3 of 5
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: C
Rationale: The correct answer is C because by 18 months of age, it is normal for a toddler to have around 12 teeth, which usually include incisors, canines, and first molars. At this age, the child is still in the process of teething, and most children have about half of their primary teeth by 18 months. Choices A, B, and D are incorrect because asking the mother about her own teeth does not address the toddler's situation, stating that all 20 deciduous teeth should be erupted by age 4 is not accurate as teething varies, and mentioning 16 teeth by age 2-4 does not specifically address the situation at 18 months.
Question 4 of 5
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _____ comparison.
Correct Answer: A
Rationale: The correct method is side-to-side comparison. This allows for a systematic approach by ensuring all areas are examined equally. Moving side-to-side helps to maintain consistency and accuracy in assessing lung sounds. Top-to-bottom, posterior-to-anterior, and interspace-by-interspace methods may lead to missed areas or confusion in tracking progress. Side-to-side comparison is the most effective technique for thorough auscultation.
Question 5 of 5
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:
Correct Answer: B
Rationale: The correct answer is B: Postnasal drip or sinusitis. This is because a cough that worsens at night but improves during the day is a common symptom of postnasal drip or sinusitis, where mucus drips down the back of the throat when lying down. Other choices are incorrect because pneumonia typically presents with a persistent cough throughout the day, exposure to irritants at work would not cause a cough pattern specific to nighttime, and chronic bronchial irritation from smoking would result in a more persistent and continuous cough regardless of the time of day.