ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
The nurse is assessing a patient's mental status and notes that the patient is unable to remember recent events. Which aspect of memory is impaired?
Correct Answer: C
Rationale: Recent memory is the ability to recall information from the past few minutes to a few hours, which is impaired in this case.
Question 2 of 5
The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection , where warm air around the body is replaced by cooler moving air. Radiation involves heat emission without contact, not fan-driven. Conduction requires direct contact (e.g., cold pack), not air movement. Evaporation involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
Question 3 of 5
While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?
Correct Answer: B
Rationale: The S3 is a normal finding in children. The venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.
Question 4 of 5
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: A stronger percussion stroke is needed for obese or muscular individuals.
Question 5 of 5
Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next?
Correct Answer: C
Rationale: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6–12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.