ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
Correct Answer: D
Rationale: The correct answer is D because it follows the proper sequence for abdominal palpation. Light palpation should always precede deep palpation to detect surface characteristics and allow the patient to get accustomed to being touched. This approach helps the nurse gather initial information and establish rapport with the patient. Palpating reportedly tender areas should not be avoided (Choice A) as it is important to assess all areas for potential issues. Quickly palpating a tender area (Choice B) may cause unnecessary discomfort to the patient. Beginning with deep palpation (Choice C) before light palpation is not recommended as it may cause discomfort and prevent the nurse from effectively assessing the abdomen.
Question 2 of 5
You are a student in the vascular surgery clinic. You are asked to perform a physical examination on a patient with known peripheral vascular disease in the legs. Which of the following aspects is important to note when you perform your examination?
Correct Answer: A
Rationale: Rationale for correct answer (A): - Size: Helps assess for muscle wasting or swelling. - Symmetry: Indicates potential arterial occlusion or venous insufficiency. - Skin color: Changes may suggest poor perfusion or venous stasis. Summary of incorrect choices: - B: Muscle bulk and tone are important but secondary to circulation assessment. - C: Nodules in joints are more relevant to rheumatologic conditions. - D: Lower extremity strength is important but not as critical for vascular assessment.
Question 3 of 5
The client after having a haemorrhagic stroke has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?
Correct Answer: A
Rationale: The correct answer is A. Giving the client thin liquids can be dangerous for someone with dysphagia as it can increase the risk of aspiration. Thickening liquids to the consistency of oatmeal helps prevent aspiration. Placing food on the unaffected side of the mouth can assist in swallowing. Allowing plenty of time for chewing and swallowing is important for safe eating.
Question 4 of 5
A client arrives in the emergency department with and is diagnosed with ischemic stroke. A possible treatment option is tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
Correct Answer: C
Rationale: The correct answer is C: Time of onset of current stroke. This is the priority nursing assessment because the effectiveness of t-PA administration is time-dependent, with a narrow window of 4.5 hours from symptom onset. Knowing the time of onset will help determine if the client is within the appropriate timeframe for t-PA administration, which can improve outcomes. A: Current medications - While important, knowing the time of onset is more critical for timely intervention in ischemic stroke. B: Complete physical and history - Important for overall assessment but not as time-sensitive as determining the stroke onset time. D: Upcoming surgical procedures - Not relevant for immediate management of ischemic stroke with t-PA.
Question 5 of 5
Which of the following is the most appropriate method for assessing skin turgor?
Correct Answer: B
Rationale: The correct answer is B: Pinching the skin over the sternum. Skin turgor is the skin's ability to return to its normal position after being pinched or pulled. The sternum is a central, flat bone that is less affected by factors like age or body fat distribution compared to other areas like the hands or abdomen. Pinching the skin over the sternum provides a more accurate assessment of skin turgor. Pinching the skin over the dorsum of the hand (A) may not be as reliable due to variations in skin thickness and elasticity. Pinching the skin over the forehead (C) and abdomen (D) are not ideal locations for assessing skin turgor as they are not commonly used for this purpose in clinical practice.