ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?
Correct Answer: C
Rationale: The correct answer is C. When the blood pressure in the arm is high in an adolescent, it should be compared with thigh pressure. This is because in certain conditions like coarctation of the aorta, there can be a significant difference in blood pressure between the arms and thighs. By comparing arm and thigh pressures, the nurse can assess for potential underlying cardiovascular issues. A: Auscultating the popliteal or femoral vessels is not necessary for obtaining thigh pressure as the correct method is comparing arm and thigh pressures. B: The position for measuring thigh pressure is not specified, and the focus should be on comparing arm and thigh pressures. D: The difference in pressure between the arm and thigh is not solely due to distance from the heart and vessel size; it can be indicative of cardiovascular abnormalities.
Question 2 of 5
A patient has had a 'terrible itch' for several months that he has been continuously scratching. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: Lichenification. Lichenification is a skin condition characterized by thickening and hardening of the skin due to chronic irritation or scratching. In this case, the patient's continuous scratching of the itch has led to lichenification. This is evident by the rough and leathery texture of the skin upon examination. A: A keloid is an overgrowth of scar tissue that can occur after a wound heals, not typically associated with chronic scratching. B: A fissure is a small, painful crack in the skin that can occur due to dryness or trauma, not a result of continuous scratching. C: Keratosis refers to various skin conditions characterized by thickening of the skin, but it is not specifically associated with chronic scratching like lichenification. In summary, lichenification is the most likely finding in this scenario due to the chronic scratching leading to skin thickening and hardening.
Question 3 of 5
A patient with a middle ear infection asks the nurse, 'What does the middle ear do?' The nurse responds by telling the patient that the middle ear functions to:
Correct Answer: C
Rationale: The correct answer is C: Conduct vibrations of sounds to the inner ear. The middle ear consists of the eardrum and three small bones that transmit sound vibrations from the eardrum to the inner ear. This process allows sound waves to be converted into electrical signals that can be interpreted by the brain. Choice A is incorrect because balance is primarily controlled by structures in the inner ear, not the middle ear. Choice B is incorrect as interpreting sounds happens in the inner ear and brain, not the middle ear. Choice D is incorrect because the middle ear does not increase the amplitude of sound; rather, it amplifies and transmits sound vibrations to the inner ear for further processing.
Question 4 of 5
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):
Correct Answer: B
Rationale: The correct answer is B: Acute otitis media. In this case, the bright red tympanic membrane and the absence of the light reflex suggest inflammation and infection of the middle ear, which are characteristic of acute otitis media. The child's symptoms of pulling on his ear also support this diagnosis. A: Fungal infection typically presents with white patches and not necessarily redness or absence of light reflex. C: Perforation of the eardrum would show a visible hole in the tympanic membrane. D: Cholesteatoma is a noncancerous growth that would present differently on otoscopic examination.
Question 5 of 5
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
Correct Answer: B
Rationale: The correct answer is B: Firm pressure. When palpating sinus areas, normal findings should elicit a sensation of firm pressure. This is because the sinuses are air-filled cavities that should not cause pain or discomfort when palpated. Sensing firm pressure indicates normal sinus function. Choices A, C, and D are incorrect because normal sinus palpation should not result in no sensation, pain during palpation, or pain sensation behind the eyes. These sensations could indicate sinus inflammation, infection, or other abnormalities that should be further assessed.