ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A student is late for his appointment and has rushed across campus to the health clinic. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because allowing the student 5 minutes to relax and rest before checking his vital signs is important for obtaining accurate readings. When someone rushes across campus, their heart rate and blood pressure are likely elevated, which can lead to inaccurate readings if taken immediately. Allowing the student to relax will help stabilize their vital signs and provide a more accurate baseline measurement. Choice B is incorrect because checking blood pressure in both arms expecting a difference due to recent exercise is not necessary in this scenario. Choice C is incorrect as immediate monitoring may not provide accurate readings due to the student's rushed state. Choice D is incorrect as checking blood pressure in the supine position is not necessary and may not accurately reflect the student's true vital signs in this situation.
Question 2 of 5
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign vascular growths that appear as small, bright red dots on the skin, often found in older individuals. In this case, the patient is a 42-year-old woman, which fits the age range for senile angiomas. Anasarca (A) is generalized edema, not related to the described skin findings. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not typically presenting as bright red dots. Latent myeloma (D) is a type of blood cancer and not associated with the described skin lesions.
Question 3 of 5
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's:
Correct Answer: D
Rationale: The correct answer is D: Abdomen. The nurse should test skin mobility and turgor over the infant's abdomen because it is a reliable indicator of dehydration in infants. Dehydration can lead to decreased skin turgor, meaning that the skin will not bounce back quickly when pinched. The abdomen provides a larger surface area for assessment compared to the other options, making it easier to evaluate skin mobility and turgor accurately. Testing on the sternum, forehead, or forearms may not provide a clear assessment of dehydration in infants. Therefore, choosing the abdomen for skin mobility and turgor assessment is the most appropriate and reliable option in this scenario.
Question 4 of 5
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?
Correct Answer: B
Rationale: The correct answer is B because bloody or clear watery drainage can indicate a basal skull fracture, which is a serious complication of head injuries. Assessing for this type of drainage is crucial as it may signify a potentially life-threatening condition that requires immediate medical attention. A: Incorrect. Purulent drainage resulting from a ruptured eardrum is concerning but not as immediately life-threatening as a basal skull fracture. C: Incorrect. Increased cerumen occluding the auditory canal is not as urgent as identifying a basal skull fracture. D: Incorrect. While foreign bodies in the ear canal are important to assess, they are not as critical as identifying a basal skull fracture.
Question 5 of 5
The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:
Correct Answer: A
Rationale: Step-by-step rationale for Answer A: 1. Leukoedema is a common benign condition characterized by grayish-white lesions in the mouth. 2. It is more prevalent in dark-skinned individuals, like Black patients. 3. The lesion described matches the characteristics of leukoedema - nontender, grayish-white, and common in dark-pigmented individuals. 4. Therefore, the correct answer is A. Summary of why other choices are incorrect: B: Hyperpigmentation does not present as grayish-white lesions and is not normal in this context. C: Torus palatinus is a bony growth on the roof of the mouth, not a lesion on the buccal mucosa. D: Cancerous lesions usually have different characteristics and require further evaluation beyond a visual assessment.