ATI RN
Vital Signs Assessment Quizlet Questions
Question 1 of 5
Induration along the ventral surface of the penis suggests which of the following?
Correct Answer: A
Rationale: Urethral stricture may cause induration of the ventral surface of the penis. It more rarely represents a local carcinoma. A testicular carcinoma would be much more likely to occur in the scrotum. Peyronie's disease often causes induration on the dorsal proximal penis, and epidermoid cysts are benign findings on the scrotum.
Question 2 of 5
During a routine office visit, a patient takes off his shoes and shows the nurse 'this awful sore that won't heal.' On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Arterial ischemic ulcer. The key indicators for this type of ulcer include a pale ischemic base, well-defined edges, and no drainage, which align with the description of the ulcer on the patient's toe. Arterial ischemic ulcers typically occur due to poor blood circulation, often associated with conditions like peripheral artery disease. Option A) Varicosities refers to enlarged, twisted veins usually seen in the legs, but they do not typically present as ulcers like the one described. Option B) Venous stasis ulcer is associated with venous insufficiency and commonly presents with irregular wound edges and may have drainage. Option D) Deep-vein thrombophlebitis involves a blood clot in a deep vein and presents with swelling, redness, and warmth along the affected vein rather than an ulcer. Understanding the characteristics of different types of ulcers is crucial for nurses to provide appropriate care and interventions. Recognizing the specific signs and symptoms helps in accurate diagnosis and timely treatment to prevent complications and promote healing. This case highlights the importance of thorough assessment and knowledge of various wound etiologies in clinical practice.
Question 3 of 5
You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of:
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Cheyne-Stokes respiration. Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by shallow, slow breathing and apnea. This pattern is often seen in patients with heart failure, brain injuries, or other conditions affecting the respiratory centers in the brain. The patient's lack of distress despite the abnormal breathing pattern is a key characteristic of Cheyne-Stokes respiration. Option A) Ataxic (Biot's) breathing is characterized by unpredictable irregularity in the depth and rate of breathing, often seen in patients with brain injuries. This does not match the described pattern of deepening and shallowing breaths. Option C) Kussmaul's respiration is deep, rapid, and labored breathing often seen in patients with metabolic acidosis. This pattern does not align with the described breathing pattern in the patient with heart failure. Option D) COPD with prolonged expiration would not present with the described pattern of progressively deeper and shallower breaths followed by apnea. COPD typically presents with prolonged expiration due to air trapping in the lungs. Understanding and recognizing abnormal breathing patterns like Cheyne-Stokes respiration is crucial for healthcare providers to appropriately assess and manage patients with respiratory compromise. By differentiating between these patterns, healthcare professionals can provide timely and effective interventions to support patient respiratory function and overall well-being.
Question 4 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. a. Blood pressure 74/50, HR 148
Correct Answer: A
Rationale: In this scenario, the correct answer is A) First-level priority. The reason for this is that the patient's vital signs indicate a critical situation requiring immediate attention. A blood pressure of 74/50 and a heart rate of 148 suggest hypotension and tachycardia, which could indicate a life-threatening condition such as shock. Choosing option B) Second-level priority would be incorrect because vital signs as abnormal as these require immediate intervention to stabilize the patient before addressing other less urgent issues. Option C) Third-level priority is also incorrect because waiting to address the critically abnormal vital signs could result in deterioration of the patient's condition and potential harm. From an educational standpoint, understanding how to prioritize patient care based on the urgency of the situation is crucial in healthcare. Recognizing and responding to abnormal vital signs promptly can make a significant difference in patient outcomes. This question highlights the importance of recognizing first-level priority problems that require immediate action to ensure patient safety and well-being.
Question 5 of 5
Mark each of the following statements as therapeutic or nontherapeutic. g. "You must not eat or drink anything after midnight except for small sips of water to take your morning pills."
Correct Answer: A
Rationale: The correct answer is A) Therapeutic. This statement is considered therapeutic because it provides clear and specific instructions for a patient regarding their pre-medication dietary restrictions. By specifying not to eat or drink anything after midnight except for small sips of water to take morning pills, it ensures that the medication is absorbed optimally and that potential adverse interactions with food are minimized. This guidance promotes the effectiveness and safety of the medication regimen, which is essential in healthcare settings. Option B) Nontherapeutic is incorrect because the statement given is actually therapeutic in nature as it aims to enhance the intended therapeutic outcomes of the medication by controlling the patient's dietary intake. Educational Context: Understanding the distinction between therapeutic and nontherapeutic communication is crucial in healthcare, especially for healthcare professionals such as nurses, doctors, and medical assistants. Therapeutic communication involves providing clear, supportive, and client-centered information that promotes positive health outcomes. Nontherapeutic communication, on the other hand, may hinder effective patient care and can lead to misunderstandings or negative health consequences. In the context of vital signs assessment, clear communication about medication administration instructions, including dietary restrictions, is essential for patient safety and treatment effectiveness. By recognizing and using therapeutic communication techniques, healthcare providers can build trust with patients, enhance adherence to treatment plans, and ultimately improve patient outcomes.