ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?
Correct Answer: A
Rationale: The correct answer is A: "How do you feel today?" because affect refers to the patient's observable emotional expression. By asking this question, the nurse can assess the patient's emotional state, mood, and overall demeanor. Choices B, C, and D do not specifically address the patient's affect. Choice B focuses on memory and cognitive function, choice C relates to medication effectiveness, and choice D addresses the physical impact of pain on activities of daily living. It is important to ask about the patient's affect to understand their emotional well-being during the mental status examination.
Question 2 of 5
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique indicates that more review is needed?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Percussing once over each area is incorrect because percussion should involve multiple strikes to accurately assess underlying structures. 2. Percussion requires a series of light and rapid strikes to elicit different sounds based on tissue density. 3. By percussing only once, the nurse may miss subtle differences in sound pitch and quality, leading to inaccurate assessments. 4. Therefore, more review is needed to ensure the nurse understands the importance of multiple percussion strikes for proper assessment. Summary of other choices: B. Quickly lifting the striking finger after each stroke is a correct technique to enhance the accuracy of percussion. C. Striking with the fingertip, not the finger pad, is important to produce clear sounds during percussion. D. Using the wrist to make the strikes, not the arm, is the correct technique to achieve controlled and precise percussion strikes.
Question 3 of 5
When auscultating for bowel sounds, the nurse should:
Correct Answer: C
Rationale: The correct answer is C: Use the diaphragm of the stethoscope. The diaphragm is the appropriate part of the stethoscope for listening to bowel sounds due to its ability to pick up higher frequency sounds. Bowel sounds are best heard with a higher frequency range, which the diaphragm is designed to capture. Using the bell of the stethoscope (choice A) is not ideal for bowel sounds as it is better suited for low-frequency sounds like heart murmurs. Ensuring the patient is standing upright (choice B) is unnecessary for auscultating bowel sounds. Avoiding pressing the stethoscope too firmly (choice D) is a good practice to prevent unnecessary noise interference, but it is not directly related to the optimal choice of stethoscope component for bowel sounds.
Question 4 of 5
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should:
Correct Answer: D
Rationale: The correct answer is D. A tripod position, where a patient leans forward with arms braced on a chair, is often used when a patient is having respiratory difficulties, such as in asthma exacerbation. This position helps improve airflow by allowing better expansion of the chest. The patient is likely trying to relieve breathing difficulty by maximizing lung expansion. Choosing option D is appropriate as it acknowledges the significance of the tripod position in respiratory distress. A: This choice is incorrect because assuming the patient is eager and interested in participating in the interview does not relate to the observation of the tripod position in a patient with asthma. B: Evaluating the patient for abdominal pain is not the priority in this scenario where respiratory distress is suspected. C: This option is incorrect as moving the patient to a supine position may worsen breathing difficulties.
Question 5 of 5
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?
Correct Answer: C
Rationale: The correct answer is C. When the blood pressure in the arm is high in an adolescent, it should be compared with thigh pressure. This is because in certain conditions like coarctation of the aorta, there can be a significant difference in blood pressure between the arms and thighs. By comparing arm and thigh pressures, the nurse can assess for potential underlying cardiovascular issues. A: Auscultating the popliteal or femoral vessels is not necessary for obtaining thigh pressure as the correct method is comparing arm and thigh pressures. B: The position for measuring thigh pressure is not specified, and the focus should be on comparing arm and thigh pressures. D: The difference in pressure between the arm and thigh is not solely due to distance from the heart and vessel size; it can be indicative of cardiovascular abnormalities.