ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse notes a drumlike percussion sound over the abdomen. This indicates:
Correct Answer: B
Rationale: The drumlike percussion sound over the abdomen suggests air-filled areas. This occurs because air in the stomach or intestines resonates when tapped, creating a hollow sound. This finding is consistent with conditions like gastric distention or bowel obstruction. Constipation (A) would not typically produce a drumlike sound. The presence of a tumor (C) or dense organs (D) would not lead to this specific percussion finding.
Question 2 of 5
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
Correct Answer: B
Rationale: The correct answer is B: Detect the presence of an auscultatory gap. Performing a palpated pressure before auscultating blood pressure helps detect an auscultatory gap, which is a period of silence between the systolic and diastolic readings. This is important because relying solely on Korotkoff sounds may lead to missing this gap, resulting in inaccurate blood pressure readings. The other choices are incorrect because: A: More clearly hearing Korotkoff sounds is not the primary purpose of palpated pressure. C: Palpated pressure does not specifically help avoid missing a falsely elevated blood pressure. D: Identifying phase IV of Korotkoff sounds is not the main objective of performing palpated pressure.
Question 3 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 4 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 5 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.