ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Increased ICP can lead to cerebral edema and worsen neurological outcomes. 2. Promoting carbon dioxide elimination helps reduce cerebral blood flow and intracranial pressure. 3. Hyperventilation decreases PaCO2, causing vasoconstriction and reducing ICP. 4. Preventing respiratory alkalosis (A) and lowering arterial pH (B) are incorrect as they can worsen cerebral vasoconstriction. 5. Maintaining PaO2 above 80 mm Hg (D) is important but not the primary goal in managing increased ICP.
Question 2 of 5
The nurse is preparing to assess a patient's deep tendon reflexes. Which tool is most appropriate for this assessment?
Correct Answer: B
Rationale: The correct answer is B: Reflex hammer. This tool is specifically designed to assess deep tendon reflexes by eliciting a quick stretch reflex response. The pointed end of the reflex hammer is used to strike the tendon, causing a quick tap that triggers the reflex. The other choices are incorrect: A tuning fork is used for testing auditory sensations, a penlight is used for assessing pupillary responses and examining the eyes, and an otoscope is used for visualizing the ear canal and eardrum. Therefore, the reflex hammer is the most appropriate tool for assessing deep tendon reflexes due to its specific design and function.
Question 3 of 5
What is the primary purpose of using the Snellen chart during a physical examination?
Correct Answer: C
Rationale: The primary purpose of using the Snellen chart during a physical examination is to measure visual acuity, which refers to the sharpness of vision. The chart consists of letters or symbols of varying sizes that the individual is asked to read from a specific distance. By determining the smallest line of text that can be read accurately, the healthcare provider can assess the clarity of the individual's vision. Peripheral vision, depth perception, and color vision are not evaluated using the Snellen chart, making choices A, B, and D incorrect.
Question 4 of 5
What is the primary purpose of palpating the costovertebral angle during an abdominal assessment?
Correct Answer: B
Rationale: The primary purpose of palpating the costovertebral angle during an abdominal assessment is to evaluate kidney tenderness. This area is specifically associated with the kidneys, so tenderness in this region could indicate renal issues. Palpating for rebound tenderness (choice A) is typically done in the abdominal quadrants, not the costovertebral angle. Checking for abdominal aortic pulsation (choice C) is usually done in the epigastric area, not the costovertebral angle. Assessing liver size (choice D) is typically done by percussion and palpation in the right upper quadrant, not at the costovertebral angle.
Question 5 of 5
The nurse is assessing a patient's pupillary response and observes that both pupils constrict when light is directed into one eye. What does this finding indicate?
Correct Answer: B
Rationale: The correct answer is B: Consensual light reflex. When both pupils constrict in response to light directed into one eye, it indicates a consensual light reflex. This response occurs due to the connection between the optic nerves, causing both pupils to constrict simultaneously. This reflex is an involuntary response and ensures that both eyes react to changes in light intensity equally. Choice A (Direct light reflex) refers to the constriction of the pupil in response to light directly shining into that same eye, not both eyes simultaneously. Choice C (Accommodation) involves the adjustment of the lens to focus on near objects and is not related to pupillary response. Choice D (Convergence) refers to the inward movement of both eyes when focusing on a nearby object and is not related to pupillary response to light.