ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
The nurse is assessing a patient's peripheral pulses. Which pulse is located at the back of the knee?
Correct Answer: B
Rationale: The popliteal pulse is located behind the knee, where the femoral artery passes through the popliteal fossa.
Question 2 of 5
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 3 of 5
Mark each of the following statements as therapeutic or nontherapeutic. h. "No need to cry. Let's move on to a different topic."
Correct Answer: B
Rationale: This statement dismisses the patient's emotions and is nontherapeutic.
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
After striking their head on a tree while falling from a ladder, the patient is admitted unconscious with nonreactive pupils. Which intervention would be the most dangerous for the client?
Correct Answer: D
Rationale: A lumbar puncture in the presence of increased ICP can cause brain herniation.