ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 9
The nurse is performing a musculoskeletal assessment and notes that the patient has a decreased range of motion in the knee joint. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Decreased range of motion in the knee joint is often a result of osteoarthritis, a condition characterized by the degeneration of joint cartilage.
Question 2 of 9
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States?
Correct Answer: C
Rationale: Black women have a higher mortality rate from breast cancer than white women and are more likely to die of their disease. In addition, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortality rates may be related to an insufficient use of screening measures and a lack of access to health care.
Question 3 of 9
A pregnant woman states, 'I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor.' The nurse responds by stating, 'Oh, don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.' Which statement is true regarding this response? The nurse's reply was a:
Correct Answer: B
Rationale: By providing false assurance or reassurance, this courage builder relieves the woman's anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.
Question 4 of 9
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 5 of 9
Core body temperature is highest at:
Correct Answer: C
Rationale: Late afternoon, is correct because core body temperature peaks around 4 pm to 6 pm due to circadian rhythms governed by the hypothalamus. It rises throughout the day from a low of ~97°F (4-6 am) to a high of ~98.6°F-100°F, reflecting increased metabolic activity. Early morning, is the nadir, not peak. Noon, is midway, not the highest. Evening, sees a decline post-peak. Studies show this diurnal pattern in healthy adults, with late afternoon aligning with maximal alertness and physical performance. Nurses consider this when assessing fevere.g., a 99°F reading at 5 pm might be normal variation. Thus, C is accurate based on physiological circadian evidence.
Question 6 of 9
A nurse is conducting a health assessment for an African American patient. What should the nurse consider in terms of cultural sensitivity?
Correct Answer: C
Rationale: Cultural risk factors and racial variations , per the answer key, guide sensitive assessments (e.g., hypertension in African Americans). Uniformity , race questions , or emotional needs miss this focus. Nurses, per Taylor, adapt care culturally.
Question 7 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 8 of 9
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
Correct Answer: A
Rationale: Newborn respiratory rate is 30-60 breaths/min; rapid breathing within this is normal if pink, warm, dry. Lower ranges (B, C, D) apply to older ages. Choice A is correct, per neonatal norms, guiding care planning.
Question 9 of 9
While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?
Correct Answer: B
Rationale: The S3 is a normal finding in children. The venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.