ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination?
Correct Answer: A
Rationale: The correct answer is A: Increased cup-to-disc ratio. On funduscopic examination of a patient with glaucoma, one would typically observe an increased cup-to-disc ratio, indicating optic nerve damage. This is a key feature of glaucoma diagnosis as it signifies progressive loss of retinal ganglion cells. AV nicking, cotton wool spots, and microaneurysms are not specific findings in glaucoma, but rather associated with other conditions such as hypertensive retinopathy and diabetic retinopathy. Therefore, they are not indicative of glaucoma on funduscopic examination.
Question 2 of 5
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?
Correct Answer: A
Rationale: The correct answer is A because percussing once over each area is not an appropriate technique. Percussion involves tapping the body surface repeatedly to produce sound waves. By percussing only once, the nurse may not accurately assess the underlying structures. Choices B, C, and D are incorrect because lifting the striking finger quickly, striking with the fingertip, and using the wrist are all appropriate percussion techniques that allow for proper assessment of underlying structures.
Question 3 of 5
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This action should be taken next because it can provide valuable information about the underlying cause of the patient's respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the lungs or pleural space, which could be contributing to the breathing difficulties. It is an important assessment technique to determine if there are changes in lung density or presence of abnormal sounds. Counting respirations (A) is important but may not provide immediate information on the cause of distress. Waiting for a chest x-ray (C) can delay necessary interventions. Inspecting the thorax for masses or bleeding (D) is not as crucial as assessing for changes in percussion tones in a patient experiencing sudden respiratory distress.
Question 4 of 5
The nurse is assessing a patient for signs of dehydration. Which finding is consistent with dehydration?
Correct Answer: C
Rationale: Correct Answer: C - Dry, cracked lips. Rationale: 1. Dehydration leads to decreased fluid intake and can cause dryness in the body. 2. Dry, cracked lips are a common sign of dehydration due to lack of moisture. 3. Moist mucous membranes (A) and increased skin turgor (B) are actually signs of hydration. 4. Elevated blood pressure (D) is not typically associated with dehydration; it may indicate other health issues.
Question 5 of 5
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
Correct Answer: C
Rationale: The correct answer is C: Schedule for a STAT computer tomography (CT) scan of the head. This is the priority intervention because the client is showing symptoms of a possible stroke, such as slurred speech and weakness. A CT scan will help determine if the symptoms are indeed caused by a stroke and guide further treatment. Administering rt-PA (choice A) should only be done after confirming a diagnosis of ischemic stroke to prevent complications. Discussing precipitating factors (choice B) and consulting a speech pathologist (choice D) are important but not as urgent as ruling out a stroke with a CT scan.