ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
Correct Answer: D
Rationale: The correct answer is D: Replaced every 4 weeks. The epidermis is continuously renewing itself through a process called desquamation, where old cells are shed and replaced by new ones. This turnover process typically takes around 4 weeks. This statement would be included in the module to educate the nursing staff on the dynamic nature of the epidermis. A: Highly vascular is incorrect because the epidermis is avascular, meaning it does not contain blood vessels. B: Thick and tough is incorrect as the epidermis is actually thin and serves as a protective barrier for the body. C: Thin and nonstratified is incorrect because the epidermis is stratified, consisting of multiple layers of cells.
Question 2 of 5
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloration in the woman's face, nail beds, lips, and oral mucosa suggests carbon monoxide poisoning due to the formation of carboxyhemoglobin. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red appearance. Polycythemia would not cause this specific color change. Carotenemia results in a yellow-orange skin tint, not cherry-red. Uremia typically presents with symptoms related to kidney dysfunction, such as fluid retention and electrolyte imbalances, not skin discoloration.
Question 3 of 5
In performing a voice test to assess hearing, which of these actions would the nurse perform?
Correct Answer: B
Rationale: The correct answer is B because whispering random numbers and letters and asking the patient to repeat them is a common method used in voice tests to assess hearing ability. This test evaluates both the patient's ability to hear and understand speech at a normal conversation level. Whispering ensures that the patient relies solely on their auditory ability without any visual cues. A: Shielding the lips would hinder the patient's ability to hear the nurse clearly, making it an inappropriate action for a voice test. C: Asking the patient to occlude outside noise by placing a finger in the ear is not part of a standard voice test procedure and does not assess hearing directly. D: Standing 4 feet away doesn't provide a standardized or controlled environment for a voice test and may not accurately evaluate the patient's hearing ability.
Question 4 of 5
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B because when a patient experiences a nosebleed, sitting up with the head tilted forward and pinching the nose helps to apply pressure to the bleeding area, promoting clotting and stopping the bleeding. This position also prevents blood from flowing down the throat, which can cause choking or swallowing blood. Placing a cold compress while sitting up (choice A) can help constrict blood vessels, but the key action of applying pressure by pinching the nose is missing. Allowing bleeding to stop on its own (choice C) without taking any immediate action could lead to excessive blood loss. Lying on the back with the head tilted back (choice D) is not recommended as it can cause blood to flow back into the throat and potentially lead to aspiration.
Question 5 of 5
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:
Correct Answer: C
Rationale: The correct answer is C because by 18 months of age, it is normal for a toddler to have around 12 teeth, which usually include incisors, canines, and first molars. At this age, the child is still in the process of teething, and most children have about half of their primary teeth by 18 months. Choices A, B, and D are incorrect because asking the mother about her own teeth does not address the toddler's situation, stating that all 20 deciduous teeth should be erupted by age 4 is not accurate as teething varies, and mentioning 16 teeth by age 2-4 does not specifically address the situation at 18 months.