ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
The nurse is assessing for clubbing of the fingernails and expects to find:
Correct Answer: D
Rationale: In the context of vital signs assessment, the correct answer is D) Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy. Clubbing of the fingernails is associated with certain medical conditions like respiratory or cardiovascular diseases. This abnormality presents with an angle of the nail base that is 180 degrees or greater and a nail base that feels spongy to palpation due to underlying tissue changes. Option A) Nail bases that are firm and slightly tender is incorrect because firmness and tenderness are not characteristic features of clubbing. Option B) Curved nails with a convex profile and ridges across the nails describe a different nail condition, not clubbing. Option C) Nail bases that feel spongy with an angle of the nail base of 150 degrees is incorrect as it does not meet the criteria for clubbing, which requires an angle of 180 degrees or greater. Educationally, understanding the significance of assessing for clubbing of the fingernails is crucial for nurses in detecting potential underlying health issues early. By recognizing the physical signs associated with clubbing, nurses can provide timely interventions and collaborate with healthcare providers to ensure comprehensive patient care.
Question 2 of 5
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: In this question, the correct answer is D) Frenulum. The frenulum is a band of tissue that connects the tongue to the floor of the mouth. This structure is essential for the proper movement and function of the tongue during speech and swallowing. Understanding the anatomy of the oral cavity is crucial for healthcare professionals when assessing a patient's oral health and functioning. Option A) Uvula is incorrect because the uvula is a small, fleshy projection at the back of the soft palate, not related to the tongue's connection. Option B) Palate is incorrect because the palate refers to the roof of the mouth, which is divided into the hard palate at the front and the soft palate at the back, not related to the tongue's connection. Option C) Papillae is incorrect because papillae are small raised bumps on the surface of the tongue that contain taste buds, not related to the tissue connecting the tongue to the floor of the mouth. By understanding the anatomy of the oral cavity, healthcare professionals can accurately assess and address any issues related to speech, swallowing, or oral health. This knowledge is vital for providing comprehensive care to patients and ensuring their overall well-being.
Question 3 of 5
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B) When the patient first noticed the lesion. This information is crucial for the nurse to assess because the timing of when the patient first noticed the lesion can provide valuable insights into the potential cause of the ulceration. For example, if the patient recently experienced trauma to the lip or had a known exposure to a potential irritant, this could explain the presence of the ulceration. Option A) Nutritional status may be important in the overall assessment of the patient's health but is not directly relevant to the specific assessment of the ulceration on the lip. Option C) Whether the patient has had a recent cold is not as pertinent to the assessment of the mouth ulceration unless there is a suspected connection between the two. Option D) Whether the patient has had any recent exposure to sick animals is not directly related to the assessment of the mouth ulceration and would not provide as much pertinent information as knowing when the patient first noticed the lesion. Educationally, this question highlights the importance of thorough assessment and the significance of gathering detailed information to aid in making accurate clinical judgments and providing appropriate care to patients. Understanding the context and timing of symptoms is crucial in nursing assessments to establish a comprehensive picture of the patient's health status.
Question 4 of 5
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
Correct Answer: C
Rationale: The correct answer is C) Muffled voice sounds and symmetric tactile fremitus. In a normal adult lung assessment, the presence of muffled voice sounds indicates that sound is transmitted normally through the lung tissue. This is a normal finding. Symmetric tactile fremitus means that vibrations are felt equally on both sides of the chest when the patient speaks. This finding is also normal in a healthy adult. Option A) Adventitious sounds and limited chest expansion are indicative of abnormal lung findings such as crackles or wheezes, which suggest underlying respiratory conditions. Limited chest expansion may be seen in conditions like pneumonia or pleural effusion. Option B) Increased tactile fremitus and dull percussion tones are associated with lung consolidation, a condition where lung tissue becomes solid instead of filled with air. This is often seen in conditions like pneumonia. Option D) Absent voice sounds and hyperresonant percussion tones can be indicative of conditions like pneumothorax, where air accumulates in the pleural space leading to decreased or absent breath sounds and hyperresonance upon percussion. Educationally, understanding normal lung assessment findings is crucial for nurses to differentiate between normal and abnormal findings, which can guide further diagnostic and treatment decisions. By recognizing what is expected in a healthy adult lung, nurses can provide better patient care and identify early signs of respiratory issues.
Question 5 of 5
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
Correct Answer: B
Rationale: With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.