ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 9
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?
Correct Answer: A
Rationale: For irregular respiratory patterns, respirations should be counted for a full minute to ensure accuracy.
Question 2 of 9
A physical therapist plans to measure blood pressure and identifies the patient's brachial artery. The therapist knows that proper positioning of the cuff is essential. To avoid errors, the cuff should be positioned:
Correct Answer: C
Rationale: Proper blood pressure measurement requires the cuff to be directly over the brachial artery.
Question 3 of 9
The nurse is preparing to assess a hospitalized patient with significant shortness of breath. How should the nurse proceed?
Correct Answer: D
Rationale: In emergencies, a focused assessment is prioritized to address immediate concerns, with the rest done later.
Question 4 of 9
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
Correct Answer: C
Rationale: Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
Question 5 of 9
The nurse is assessing a patient for signs of anemia. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: Pale conjunctivae are a common sign of anemia due to decreased red blood cell count.
Question 6 of 9
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.
Question 7 of 9
A nurse is assessing a client's pulse rate and observes an irregular rhythm with skipped beats. What action should the nurse take?
Correct Answer: C
Rationale: Irregular rhythm with skipped beats suggests a potential arrhythmia, requiring provider notification for evaluation. It's not normal . Waiting an hour delays care. Deep breathing doesn't address cardiac issues. Choice C is correct, per the explanation, reflecting nursing's duty to escalate abnormal findings promptly for patient safety.
Question 8 of 9
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. b. Serum potassium 2.7 mmol/L (low), Glucose 225 mg/dL (high)
Correct Answer: A
Rationale: Low potassium and high glucose levels are critical and require immediate attention, making this a first-level priority.
Question 9 of 9
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.