ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
If a burn patient is splinted in a comfortable position for grafted burns to heal, the patient is at risk for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Wound contracture. When a burn patient is splinted in a comfortable position for grafted burns to heal, there is a risk of wound contracture due to prolonged immobility. Wound contracture refers to the tightening and shrinking of the skin and underlying tissues, leading to restricted joint movement and functional impairment. This complication can result in long-term disability and decreased quality of life for the patient. Choices A, B, and C are incorrect: A: Tendon rupture is not a typical complication of splinting a burn patient in a comfortable position. B: Skin breakdown may occur if the splint is too tight or if there is excessive pressure on certain areas, but it is not the primary risk associated with this scenario. C: Mechanical falls are unrelated to the positioning of the burn patient for graft healing.
Question 2 of 5
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
Correct Answer: D
Rationale: The correct answer is D because a 2.5 cm scar on the right lower forearm is an observable and measurable physical finding. Objective information in a physical assessment is data that can be directly observed or measured by the healthcare provider. Scars are physical characteristics that can be visually confirmed, making them objective. Choices A, B, and C are subjective information as they rely on the patient's report or history, which may be influenced by memory, perception, or interpretation. Therefore, they are not considered objective data.
Question 3 of 5
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
Correct Answer: C
Rationale: The correct answer is C, a complete health data base. In this initial home visit for a patient with chronic medical problems, the nurse's primary responsibility is to gather comprehensive information about the patient's health status, medical history, current medications, social support, and lifestyle factors. This type of data base allows for a holistic assessment and forms the foundation for ongoing care planning and monitoring. Choice A is incorrect because a follow-up data base is not suitable for an initial visit as it focuses on evaluating changes over time. Choice B is incorrect as an episodic data base is more appropriate for acute, single-issue visits. Choice D is incorrect as an emergency data base is used in urgent situations requiring rapid assessment and treatment, not for a routine initial visit for chronic medical problems.
Question 4 of 5
A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?
Correct Answer: B
Rationale: The correct diagnosis for this patient is external otitis (choice B). The key findings that support this diagnosis include pain on manipulation of the ear, especially the tragus, narrowed and erythematous ear canal, drainage, and white debris in the canal. These are classic signs of external otitis, also known as swimmer's ear, which is an infection of the ear canal. Otitis media (choice A) typically presents with middle ear inflammation and fluid accumulation, but this patient's symptoms are more consistent with an external ear infection. Perforation of the tympanum (choice C) would present with different symptoms, such as hearing loss, ear discharge, and possible pain, but the examination findings described do not suggest a perforation. Cholesteatoma (choice D) is a benign growth in the middle ear and does not typically present with the external ear canal findings described in the patient.
Question 5 of 5
Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next?
Correct Answer: A
Rationale: The correct answer is A: Obtain an abdominal ultrasound. A pulsatile mass in an elderly smoker raises concern for an abdominal aortic aneurysm (AAA). An abdominal ultrasound is the best initial diagnostic test to confirm the presence of an AAA. If left untreated, AAA can lead to life-threatening complications such as rupture. Choice B (Reassess in 6 months) and C (Reassess in 3 months) are incorrect as immediate investigation is necessary due to the potential seriousness of an AAA. Choice D (Refer to a vascular surgeon) is premature without confirming the presence of an AAA through imaging. An ultrasound is needed first to guide further management.