ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
The patient's record, laboratory studies, objective data, and subjective data combine to form the:
Correct Answer: A
Rationale: The data base includes all collected information, such as records and study results.
Question 2 of 5
During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:
Correct Answer: C
Rationale: Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen.
Question 3 of 5
What is the best position for the nurse to place the patient in when assessing jugular vein distension?
Correct Answer: A
Rationale: Jugular vein distension is best assessed with the head of the bed elevated 30 to 45 degrees.
Question 4 of 5
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 5 of 5
After striking their head on a tree while falling from a ladder, the patient is admitted unconscious with nonreactive pupils. Which intervention would be the most dangerous for the client?
Correct Answer: D
Rationale: A lumbar puncture in the presence of increased ICP can cause brain herniation.