ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
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 2 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.
Question 3 of 5
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 5
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 5 of 5
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, 'I buy obie get spirding and take my train.' What is the best description of this patient's problem?
Correct Answer: D
Rationale: In Wernicke's aphasia, speech is fluent but incomprehensible with word substitutions and made-up words. Patients often have a strong urge to speak but their speech lacks meaningful content.