ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing a general survey. Which action is a component of the general survey?
Correct Answer: A
Rationale: The correct answer is A because observing the patient's body stature and nutritional status is a key component of the general survey, which involves assessing the overall appearance and health status of the patient. This step provides valuable information about the patient's overall well-being and can help identify any potential health issues. Choice B is incorrect because interpreting subjective information reported by the patient is part of the health history, not the general survey. Choice C is incorrect because measuring vital signs (temperature, pulse, respirations, and blood pressure) is part of the physical assessment, not the general survey. Choice D is incorrect because observing specific body systems while performing the physical assessment is also not part of the general survey, but rather a focused assessment on particular body systems.
Question 2 of 5
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
Correct Answer: C
Rationale: The correct answer is C: Systolic blood pressure may be falsely low. An auscultatory gap is a silent interval between the Korotkoff sounds during blood pressure measurement, commonly seen in hypertension. If the nurse does not check for an auscultatory gap, they may miss this silent interval, leading to an underestimation of the systolic blood pressure. Choices A and B are incorrect because missing an auscultatory gap does not affect the ability to hear diastolic blood pressure or result in a falsely low diastolic reading. Choice D is incorrect as missing an auscultatory gap would not lead to a falsely high systolic blood pressure.
Question 3 of 5
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
Correct Answer: C
Rationale: The correct answer is C: Distended veins. When a patient has been confined with his feet down for an extended period, it can lead to venous pooling in the lower extremities, causing the veins to become distended. This occurs due to decreased venous return and increased pressure in the veins. Pallor, coolness, and prolonged capillary filling time would not be expected findings in this situation as they are more indicative of arterial insufficiency or decreased perfusion, which is not the primary concern in this scenario. Distended veins are a common manifestation of venous stasis, making it the most appropriate choice in this context.
Question 4 of 5
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this scenario, the presence of bilateral pitting edema in a patient with a history of hypertension and coronary artery disease suggests fluid overload due to heart failure. The puffy and tight skin without redness or tenderness indicates the edema is non-inflammatory. Equal and strong peripheral pulses suggest good circulation, ruling out venous thrombosis. Absence of signs like redness, warmth, or pain in the legs excludes local inflammation. Blockage of lymphatic drainage typically presents with unilateral edema and is less common in this patient population. Therefore, given the patient's history and physical findings, heart failure is the most likely cause of the bilateral pitting edema.
Question 5 of 5
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:
Correct Answer: A
Rationale: The correct answer is A: Otosclerosis. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, specifically the stapes bone. This abnormal bone growth can lead to conductive hearing loss, which may result in the patient experiencing progressive hearing loss. In this case, the patient's symptoms of hearing improvement with louder sounds or increased volume suggest a conductive hearing loss, which is common in otosclerosis. Choice B: Presbycusis, is age-related hearing loss and typically presents as a gradual decline in hearing over time, not necessarily with a sudden progressive loss as described in the scenario. Choice C: Trauma to the bones would likely result in a more sudden onset of hearing loss, not a progressive loss as described in the scenario. Choice D: Frequent ear infections may lead to temporary hearing loss due to fluid buildup or damage to the ear structures, but the symptoms described in the scenario are more indicative of a chronic condition like otosclerosis.