ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
Correct Answer: C
Rationale: The correct technique for measuring chest circumference in infants is at the nipple line, as this is the standard anatomical landmark for consistency. Measuring at this point ensures accurate and reliable data for growth monitoring. Measuring the length of an infant with a tape measure (choice A) is correct for assessing height. Weighing the infant on an electronic standing scale (choice B) is appropriate for measuring weight. Measuring head circumference by wrapping the tape measure over the nose and cheekbones (choice D) is incorrect, as it can lead to inaccurate measurements.
Question 2 of 5
During an examination, the nurse notices that a female patient has a round "moon" face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition?
Correct Answer: C
Rationale: The correct answer is C: Cushing syndrome. This condition is characterized by the symptoms described - "moon" face, central trunk obesity, cervical hump, fragile skin with bruises - due to excessive cortisol production. Marfan syndrome (A) is a genetic disorder affecting connective tissue, leading to tall stature and long limbs. Gigantism (B) is caused by excess growth hormone before puberty, resulting in abnormal growth. Acromegaly (D) is similar to gigantism but occurs after growth plates have closed, causing enlargement of bones and tissues. The symptoms described in the question are indicative of Cushing syndrome, thus making it the correct answer.
Question 3 of 5
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign vascular growths that appear as small, bright red dots on the skin, often found in older individuals. In this case, the patient is a 42-year-old woman, which fits the age range for senile angiomas. Anasarca (A) is generalized edema, not related to the described skin findings. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not typically presenting as bright red dots. Latent myeloma (D) is a type of blood cancer and not associated with the described skin lesions.
Question 4 of 5
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's:
Correct Answer: D
Rationale: The correct answer is D: Abdomen. The nurse should test skin mobility and turgor over the infant's abdomen because it is a reliable indicator of dehydration in infants. Dehydration can lead to decreased skin turgor, meaning that the skin will not bounce back quickly when pinched. The abdomen provides a larger surface area for assessment compared to the other options, making it easier to evaluate skin mobility and turgor accurately. Testing on the sternum, forehead, or forearms may not provide a clear assessment of dehydration in infants. Therefore, choosing the abdomen for skin mobility and turgor assessment is the most appropriate and reliable option in this scenario.
Question 5 of 5
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?
Correct Answer: B
Rationale: The correct answer is B because bloody or clear watery drainage can indicate a basal skull fracture, which is a serious complication of head injuries. Assessing for this type of drainage is crucial as it may signify a potentially life-threatening condition that requires immediate medical attention. A: Incorrect. Purulent drainage resulting from a ruptured eardrum is concerning but not as immediately life-threatening as a basal skull fracture. C: Incorrect. Increased cerumen occluding the auditory canal is not as urgent as identifying a basal skull fracture. D: Incorrect. While foreign bodies in the ear canal are important to assess, they are not as critical as identifying a basal skull fracture.