ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During auscultation of the heart, the nurse hears a murmur. What instrument should be used to further assess this murmur?
Correct Answer: B
Rationale: The correct answer is B: Bell of the stethoscope. The bell of the stethoscope is used to assess low-frequency sounds like heart murmurs. Murmurs are often soft and low-pitched, requiring the bell for optimal detection. The diaphragm (Choice A) is used for high-frequency sounds. The electrocardiogram (Choice C) records the heart's electrical activity, not the physical sounds. The Doppler device (Choice D) is used to assess blood flow and velocity, not heart sounds. Therefore, the bell of the stethoscope is the appropriate instrument to further assess the heart murmur.
Question 2 of 5
A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is:
Correct Answer: C
Rationale: The correct answer is C because it accurately explains that the top number (systolic pressure) reflects the pressure in the arteries when the heart contracts. This is important information as it indicates the maximum pressure exerted on the arteries during a heartbeat. The bottom number represents diastolic pressure, which is the pressure in the arteries when the heart is at rest between beats. This information helps assess overall cardiovascular health. Choice A is incorrect because just stating the numbers are normal does not provide any educational value to the patient. Choice B is incorrect as it inaccurately describes the diastolic pressure. Choice D is incorrect as it simplifies the explanation and focuses on the wrong aspect of blood pressure.
Question 3 of 5
Which of these specific measurements is the best index of a child's general health?
Correct Answer: B
Rationale: The correct answer is B: Height and weight. These measurements provide important indicators of a child's growth and development, which are key components of overall health. Height and weight measurements can help assess nutritional status, growth patterns, and potential health issues. Vital signs (A) are important for monitoring immediate health status but do not provide a comprehensive view of general health. Head circumference (C) is primarily used in infancy to assess brain development. Chest circumference (D) is not typically used as a general health indicator in children. In summary, height and weight measurements offer a holistic view of a child's health by evaluating growth, nutrition, and overall well-being.
Question 4 of 5
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:
Correct Answer: D
Rationale: The correct answer is D: Excess blood in the dilated superficial capillaries. Hyperemia is characterized by an increase in blood flow to a specific area, leading to redness. This is caused by vasodilation of superficial capillaries, allowing more blood to flow through the area. Choices A and C are incorrect because decreased amounts of bilirubin in the blood and decreased perfusion do not lead to hyperemia. Choice B is incorrect because excess blood in the underlying blood vessels does not directly cause the redness seen in hyperemia.
Question 5 of 5
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
Correct Answer: B
Rationale: The correct answer is B because the yellow color of the sclera extending up to the iris is indicative of true jaundice, known as scleral icterus. This occurs when there is an excess of bilirubin in the blood, causing yellow discoloration. Yellow patches in the outer sclera (choice A) may be due to other causes like pinguecula. Skin appearing yellow under low light (choice C) may be due to lighting conditions. Yellow deposits on palms and soles (choice D) are seen in conditions like carotenemia, not jaundice.