ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B because when a patient experiences a nosebleed, sitting up with the head tilted forward and pinching the nose helps to apply pressure to the bleeding area, promoting clotting and stopping the bleeding. This position also prevents blood from flowing down the throat, which can cause choking or swallowing blood. Placing a cold compress while sitting up (choice A) can help constrict blood vessels, but the key action of applying pressure by pinching the nose is missing. Allowing bleeding to stop on its own (choice C) without taking any immediate action could lead to excessive blood loss. Lying on the back with the head tilted back (choice D) is not recommended as it can cause blood to flow back into the throat and potentially lead to aspiration.