ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 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 2 of 5
The nurse is assessing a patient's mental status and notes that the patient is unable to remember recent events. Which aspect of memory is impaired?
Correct Answer: C
Rationale: Recent memory is the ability to recall information from the past few minutes to a few hours, which is impaired in this case.
Question 3 of 5
The nurse is preparing to assess a hospitalized patient with significant shortness of breath. How should the nurse proceed?
Correct Answer: D
Rationale: In emergencies, a focused assessment is prioritized to address immediate concerns, with the rest done later.
Question 4 of 5
The glenohumeral joint (shoulder girdle complex) involves articulation of the humeral head with the glenoid fossa. Approximately what percentage of the humeral head articulates with the glenoid fossa?
Correct Answer: B
Rationale: Approximately 30% of the humeral head articulates directly with the glenoid fossa, with the labrum increasing this contact area.
Question 5 of 5
The nurse is auscultating the lungs and hears a high-pitched sound during expiration. What does this finding most likely indicate?
Correct Answer: A
Rationale: Wheezing during expiration is a common sign of asthma, where bronchospasm causes airflow obstruction.