ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. b. Serum potassium 2.7 mmol/L (low), Glucose 225 mg/dL (high)
Correct Answer: A
Rationale: Low potassium and high glucose levels are critical and require immediate attention, making this a first-level priority.
Question 2 of 5
Which of the following is true regarding breast self-examination?
Correct Answer: C
Rationale: Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination.
Question 3 of 5
Mark each of the following statements as therapeutic or nontherapeutic. h. "No need to cry. Let's move on to a different topic."
Correct Answer: B
Rationale: This statement dismisses the patient's emotions and is nontherapeutic.
Question 4 of 5
A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?
Correct Answer: A
Rationale: Chest pain that increases with breathing is typically related to the musculoskeletal system, such as costochondritis or pleuritic pain.
Question 5 of 5
Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next?
Correct Answer: C
Rationale: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6–12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.