ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
In Erb's palsy, what part of the brachial plexus is affected?
Correct Answer: D
Rationale: In Erb's palsy, the upper trunk (C5-C6) of the brachial plexus is affected. This leads to weakness or paralysis of the shoulder and elbow muscles. The C5-C6 nerve roots are commonly injured during childbirth trauma. The other choices are incorrect because Erb's palsy specifically involves the upper trunk, not the lower trunk (C8-T1), both upper and lower trunks, or the middle trunk (C7). Therefore, the correct answer is D.
Question 2 of 5
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that require attention after addressing first-level problems but before third-level problems. Abnormal laboratory values fall into this category because they may indicate a potential for worsening health conditions if left untreated. Low self-esteem (choice A) is typically a third-level priority, lack of knowledge (choice B) can usually be addressed as a lower priority, and severely abnormal vital signs (choice D) are considered first-level priorities due to their immediate threat to the patient's well-being.
Question 3 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 4 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 5 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.