ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature?
Correct Answer: B
Rationale: The correct answer is B: Dorsal surface of the hand; the skin is thinner on this surface than on the palms. Rationale: 1. The dorsal surface of the hand has thinner skin compared to the thicker skin on the palmar surface, making it more sensitive to temperature changes. 2. Thinner skin allows for better detection of subtle temperature variations, making it ideal for accurately assessing the patient's skin temperature. 3. The fingertips (choice A) may be more sensitive to touch, but for temperature assessment, the dorsal surface is more reliable due to its thinner skin. 4. The ulnar portion of the hand (choice C) having increased blood supply does not necessarily enhance temperature sensitivity; it is more related to vascular function. 5. The palmar surface (choice D) may have increased nerve supply, but its thickness can dampen the sensitivity to detect subtle temperature changes. In summary, the correct choice (B) is supported by the anatomical characteristics of the dorsal hand
Question 2 of 5
A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. You are concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate to order to initially evaluate for this condition?
Correct Answer: C
Rationale: The correct answer is C: Ankle–brachial index (ABI). ABI is a non-invasive test used to assess peripheral vascular disease by comparing blood pressure in the ankle with blood pressure in the arm. In this case, the patient's risk factors (smoking, hypertension) make him susceptible to PVD. Venogram (A) involves injecting contrast dye into a vein to visualize blood flow, which is invasive and not typically used as an initial test. CT scan (B) is useful for imaging but not specific for PVD evaluation. PET scan (D) is used for detecting metabolic activity and is not a standard test for PVD. Therefore, C is the most appropriate initial test for evaluating PVD in this patient.
Question 3 of 5
When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: Intracranial pressure 18 mm Hg. This is the most important information to communicate because changes in ICP can indicate increasing intracranial pressure, which can lead to serious complications such as brain herniation. Monitoring and promptly communicating any changes in ICP to the healthcare provider is crucial for timely intervention and prevention of further damage. Choice A: Oral temperature 102°F is important for assessing for signs of infection or inflammation, but it is not directly related to the intracranial pressure monitoring. Choice B: Apical pulse 102 beats/min is important for assessing cardiac function, but it is not directly related to intracranial pressure monitoring. Choice D: Mean arterial pressure 90 mm Hg is important for assessing perfusion to the brain, but it is not as directly relevant to intracranial pressure monitoring as the actual ICP reading itself.
Question 4 of 5
The nurse is assessing the adaptation of the client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
Correct Answer: D
Rationale: The correct answer is D because consistently using adaptive equipment in dressing shows successful adaptation to changes in functional status after a stroke. This indicates the client's acceptance of their limitations and willingness to use tools that enable independence. Choice A is incorrect as anger towards family is not a positive sign of adaptation. Choice B suggests emotional distress, which is not indicative of successful adaptation. Choice C indicates difficulty with using modified utensils, which is a sign of struggle rather than successful adaptation.
Question 5 of 5
What is the best way for the nurse to assess for clubbing of the fingers?
Correct Answer: B
Rationale: The correct answer is B - Check the angle of the nail bed. Clubbing is characterized by an increased angle (>180 degrees) between the nail bed and the skin. This is best assessed by looking at the nail bed directly. Inspecting for white spots (A), assessing for swelling in the fingertips (C), and observing the color of the nail beds (D) are not specific or accurate indicators of clubbing. Checking the angle of the nail bed is the most direct and reliable method to assess for clubbing of the fingers.