ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique indicates that more review is needed?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Percussing once over each area is incorrect because percussion should involve multiple strikes to accurately assess underlying structures. 2. Percussion requires a series of light and rapid strikes to elicit different sounds based on tissue density. 3. By percussing only once, the nurse may miss subtle differences in sound pitch and quality, leading to inaccurate assessments. 4. Therefore, more review is needed to ensure the nurse understands the importance of multiple percussion strikes for proper assessment. Summary of other choices: B. Quickly lifting the striking finger after each stroke is a correct technique to enhance the accuracy of percussion. C. Striking with the fingertip, not the finger pad, is important to produce clear sounds during percussion. D. Using the wrist to make the strikes, not the arm, is the correct technique to achieve controlled and precise percussion strikes.
Question 2 of 5
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should:
Correct Answer: D
Rationale: The correct answer is D. A tripod position, where a patient leans forward with arms braced on a chair, is often used when a patient is having respiratory difficulties, such as in asthma exacerbation. This position helps improve airflow by allowing better expansion of the chest. The patient is likely trying to relieve breathing difficulty by maximizing lung expansion. Choosing option D is appropriate as it acknowledges the significance of the tripod position in respiratory distress. A: This choice is incorrect because assuming the patient is eager and interested in participating in the interview does not relate to the observation of the tripod position in a patient with asthma. B: Evaluating the patient for abdominal pain is not the priority in this scenario where respiratory distress is suspected. C: This option is incorrect as moving the patient to a supine position may worsen breathing difficulties.
Question 3 of 5
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?
Correct Answer: C
Rationale: The correct answer is C. When the blood pressure in the arm is high in an adolescent, it should be compared with thigh pressure. This is because in certain conditions like coarctation of the aorta, there can be a significant difference in blood pressure between the arms and thighs. By comparing arm and thigh pressures, the nurse can assess for potential underlying cardiovascular issues. A: Auscultating the popliteal or femoral vessels is not necessary for obtaining thigh pressure as the correct method is comparing arm and thigh pressures. B: The position for measuring thigh pressure is not specified, and the focus should be on comparing arm and thigh pressures. D: The difference in pressure between the arm and thigh is not solely due to distance from the heart and vessel size; it can be indicative of cardiovascular abnormalities.
Question 4 of 5
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
Correct Answer: A
Rationale: Step 1: Identify the patient's symptom - excessive dryness of the skin. Step 2: Recall the term for this condition - xerosis, characterized by dry skin. Step 3: Eliminate other choices - pruritus means itching, alopecia refers to hair loss, seborrhea is excessive oiliness. Step 4: Confirm xerosis as the best fit due to matching symptomatology. Step 5: Choose option A as the correct answer for precise description of the patient's condition.
Question 5 of 5
A patient has had a 'terrible itch' for several months that he has been continuously scratching. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: Lichenification. Lichenification is a skin condition characterized by thickening and hardening of the skin due to chronic irritation or scratching. In this case, the patient's continuous scratching of the itch has led to lichenification. This is evident by the rough and leathery texture of the skin upon examination. A: A keloid is an overgrowth of scar tissue that can occur after a wound heals, not typically associated with chronic scratching. B: A fissure is a small, painful crack in the skin that can occur due to dryness or trauma, not a result of continuous scratching. C: Keratosis refers to various skin conditions characterized by thickening of the skin, but it is not specifically associated with chronic scratching like lichenification. In summary, lichenification is the most likely finding in this scenario due to the chronic scratching leading to skin thickening and hardening.