ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Is a normal finding, and no further follow-up is necessary. The presence of dry, flaky cerumen (earwax) in the ear canal is a common and normal finding in many individuals. Cerumen plays a crucial role in protecting the ear canal by trapping dust and debris, preventing infections, and maintaining the ear's pH balance. It also helps in cleaning and lubricating the ear canal. Option A) Is a sign of an ear infection is incorrect because dry, flaky cerumen alone does not necessarily indicate an ear infection. Signs of an ear infection typically include pain, redness, swelling, and possible discharge. Option B) Represents poor hygiene is incorrect as the production and consistency of cerumen are influenced by various factors such as genetics, age, and environment, rather than just hygiene practices. Option D) Could be indicative of a change in cilia; the nurse should assess for hearing loss is incorrect because while changes in cerumen consistency can sometimes be associated with changes in cilia function, it is not the primary concern when dry, flaky cerumen is observed in a patient's ear. Educationally, understanding normal variations in physical assessments like cerumen consistency is crucial for healthcare providers to avoid unnecessary interventions or treatments. It is essential to recognize what is within the range of normal findings to provide appropriate care and avoid unnecessary alarm or interventions based on benign variations.
Question 2 of 5
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B) When the patient first noticed the lesion. This information is crucial for the nurse to assess because the timing of when the patient first noticed the lesion can provide valuable insights into the potential cause of the ulceration. For example, if the patient recently experienced trauma to the lip or had a known exposure to a potential irritant, this could explain the presence of the ulceration. Option A) Nutritional status may be important in the overall assessment of the patient's health but is not directly relevant to the specific assessment of the ulceration on the lip. Option C) Whether the patient has had a recent cold is not as pertinent to the assessment of the mouth ulceration unless there is a suspected connection between the two. Option D) Whether the patient has had any recent exposure to sick animals is not directly related to the assessment of the mouth ulceration and would not provide as much pertinent information as knowing when the patient first noticed the lesion. Educationally, this question highlights the importance of thorough assessment and the significance of gathering detailed information to aid in making accurate clinical judgments and providing appropriate care to patients. Understanding the context and timing of symptoms is crucial in nursing assessments to establish a comprehensive picture of the patient's health status.
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: The correct answer is C) Muffled voice sounds and symmetric tactile fremitus. In a normal adult lung assessment, the presence of muffled voice sounds indicates that sound is transmitted normally through the lung tissue. This is a normal finding. Symmetric tactile fremitus means that vibrations are felt equally on both sides of the chest when the patient speaks. This finding is also normal in a healthy adult. Option A) Adventitious sounds and limited chest expansion are indicative of abnormal lung findings such as crackles or wheezes, which suggest underlying respiratory conditions. Limited chest expansion may be seen in conditions like pneumonia or pleural effusion. Option B) Increased tactile fremitus and dull percussion tones are associated with lung consolidation, a condition where lung tissue becomes solid instead of filled with air. This is often seen in conditions like pneumonia. Option D) Absent voice sounds and hyperresonant percussion tones can be indicative of conditions like pneumothorax, where air accumulates in the pleural space leading to decreased or absent breath sounds and hyperresonance upon percussion. Educationally, understanding normal lung assessment findings is crucial for nurses to differentiate between normal and abnormal findings, which can guide further diagnostic and treatment decisions. By recognizing what is expected in a healthy adult lung, nurses can provide better patient care and identify early signs of respiratory issues.
Question 4 of 5
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
Correct Answer: B
Rationale: With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.
Question 5 of 5
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States?
Correct Answer: C
Rationale: Black women have a higher mortality rate from breast cancer than white women and are more likely to die of their disease. In addition, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortality rates may be related to an insufficient use of screening measures and a lack of access to health care.