ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:
Correct Answer: D
Rationale: The correct answer is D because the otoscope is a medical device specifically designed to examine the ear canal and tympanic membrane. The otoscope has a light source and a magnifying lens that allows the healthcare provider to visualize these structures. Choice A is incorrect because the otoscope is not typically used to direct light onto the sinuses. Choice B is incorrect as the otoscope uses a long, narrow speculum to visualize the ear, not a short, broad speculum. Choice C is incorrect because the otoscope is used to examine the external ear canal and tympanic membrane, not the internal ear structures.
Question 2 of 5
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
Correct Answer: B
Rationale: The correct answer is B: Nail bed pressure. This is the appropriate method to test the client's peripheral response to pain in an unconscious state. Applying pressure to the nail bed can elicit a localized pain response, indicating intact peripheral nerve function. Rationale: 1. Nail bed pressure is a sensitive area that can evoke a pain response if the client has intact peripheral nerve function. 2. Sternal rub (A) is a sternal pressure technique used to arouse a client, not specifically to test peripheral response. 3. Pressure on the orbital rim (C) is not appropriate for testing peripheral response and can be harmful. 4. Squeezing the sternocleidomastoid muscle (D) is a method to assess cranial nerve XI function, not peripheral response to pain.
Question 3 of 5
A patient recently admitted to an acute care hospital is referred to physical therapy. The physical therapist documents the following clinical signs: pallor, cyanosis, and cool skin. These clinical signs are MOST consistent with:
Correct Answer: B
Rationale: The clinical signs of pallor, cyanosis, and cool skin are indicative of poor oxygenation and circulation, which are commonly seen in anemia. Anemia leads to reduced oxygen-carrying capacity, resulting in pallor and cyanosis. Cool skin is a result of decreased blood flow. Cor pulmonale is related to right heart failure due to lung disease, not directly related to the signs described. Hypertension typically presents with elevated blood pressure, not the signs mentioned. Diaphoresis refers to excessive sweating, which is not associated with the described clinical signs. Therefore, the correct answer is B (anemia) based on the patient's presentation.
Question 4 of 5
A physical therapist reviews the medical record of a patient diagnosed with Parkinson's disease. Which clinical finding would the therapist MOST likely observe?
Correct Answer: A
Rationale: The correct answer is A: Hypertonicity. In Parkinson's disease, there is a loss of dopamine-producing cells, leading to increased muscle tone or hypertonicity. This results in stiffness and rigidity of muscles, making movements slow and difficult. Hypotonicity (B) refers to decreased muscle tone and is not typically seen in Parkinson's. Hyperreflexia (C) is an exaggerated reflex response, which is not a common feature of Parkinson's. Hyporeflexia (D) is reduced reflex response, which is not typically associated with Parkinson's disease. Hence, the most likely clinical finding in a patient with Parkinson's disease would be hypertonicity.
Question 5 of 5
A physical therapist uses an incentive spirometer with a patient post-thoracic surgery. The PRIMARY purpose of this intervention is to:
Correct Answer: D
Rationale: The correct answer is D: Prevent pulmonary complications. Using an incentive spirometer post-thoracic surgery helps prevent atelectasis and pneumonia by promoting lung expansion, improving ventilation, and clearing secretions. This intervention aids in maintaining lung function and preventing respiratory complications. A: Promote relaxation - While using an incentive spirometer may induce relaxation as a side effect, the primary purpose is not relaxation but rather to prevent pulmonary complications. B: Improve inspiratory muscle strength - Although using an incentive spirometer can help improve inspiratory muscle strength, the primary purpose is to prevent pulmonary complications. C: Reduce pain during breathing - While using an incentive spirometer may indirectly reduce pain by promoting optimal lung function, the primary purpose is to prevent pulmonary complications.