ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 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: Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
Question 2 of 5
What physical exam finding will be observed in 'Saturday night palsy'?
Correct Answer: A
Rationale: Saturday night palsy, caused by radial nerve compression, results in wrist and finger drop.
Question 3 of 5
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 4 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 5 of 5
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
Correct Answer: A
Rationale: Orthostatic blood pressure measurements (lying, sitting, and standing) are recommended for patients experiencing dizziness, especially those on antihypertensive medications.