ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
Correct Answer: A
Rationale: The correct answer is A because a tympanic membrane thermometer provides rapid measurements, making it ideal for uncooperative younger children. This is crucial in clinical settings where quick and accurate temperature readings are necessary. Choice B is incorrect as the TMT may not be the most accurate method for newborn infants due to their delicate ear structure. Choice C is incorrect as TMT devices can be relatively expensive. Choice D is incorrect as studies may not strongly support the use of TMT in children under 6 years due to factors like accuracy and reliability.
Question 2 of 5
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
Correct Answer: D
Rationale: The correct answer is D: Replaced every 4 weeks. The epidermis is continuously renewing itself through a process called desquamation, where old cells are shed and replaced by new ones. This turnover process typically takes around 4 weeks. This statement would be included in the module to educate the nursing staff on the dynamic nature of the epidermis. A: Highly vascular is incorrect because the epidermis is avascular, meaning it does not contain blood vessels. B: Thick and tough is incorrect as the epidermis is actually thin and serves as a protective barrier for the body. C: Thin and nonstratified is incorrect because the epidermis is stratified, consisting of multiple layers of cells.
Question 3 of 5
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. In patients with chronic respiratory conditions like emphysema and bronchitis, clubbing of the nails can be seen due to chronic hypoxia. This is characterized by a bulbous enlargement of the fingertips and nails curving over the fingertips. This finding is related to chronic oxygen deprivation, indicating long-standing respiratory issues. Incorrect choices: A: Anasarca - Generalized edema, not typically associated with emphysema and bronchitis. B: Scleroderma - Connective tissue disorder causing skin thickening, not directly related to respiratory conditions. C: Pedal erythema - Redness of the feet, not a common finding in emphysema and bronchitis.
Question 4 of 5
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloration in the woman's face, nail beds, lips, and oral mucosa suggests carbon monoxide poisoning due to the formation of carboxyhemoglobin. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red appearance. Polycythemia would not cause this specific color change. Carotenemia results in a yellow-orange skin tint, not cherry-red. Uremia typically presents with symptoms related to kidney dysfunction, such as fluid retention and electrolyte imbalances, not skin discoloration.
Question 5 of 5
In performing a voice test to assess hearing, which of these actions would the nurse perform?
Correct Answer: B
Rationale: The correct answer is B because whispering random numbers and letters and asking the patient to repeat them is a common method used in voice tests to assess hearing ability. This test evaluates both the patient's ability to hear and understand speech at a normal conversation level. Whispering ensures that the patient relies solely on their auditory ability without any visual cues. A: Shielding the lips would hinder the patient's ability to hear the nurse clearly, making it an inappropriate action for a voice test. C: Asking the patient to occlude outside noise by placing a finger in the ear is not part of a standard voice test procedure and does not assess hearing directly. D: Standing 4 feet away doesn't provide a standardized or controlled environment for a voice test and may not accurately evaluate the patient's hearing ability.