ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 9
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 9
Which of these would be formulated by a nurse using diagnostic reasoning?
Correct Answer: C
Rationale: Diagnostic reasoning involves formulating a diagnostic hypothesis based on collected data.
Question 3 of 9
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. b. Serum potassium 2.7 mmol/L (low), Glucose 225 mg/dL (high)
Correct Answer: A
Rationale: Low potassium and high glucose levels are critical and require immediate attention, making this a first-level priority.
Question 4 of 9
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 5 of 9
Mark each of the following statements as therapeutic or nontherapeutic. h. "No need to cry. Let's move on to a different topic."
Correct Answer: B
Rationale: This statement dismisses the patient's emotions and is nontherapeutic.
Question 6 of 9
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
Correct Answer: A
Rationale: Orthostatic blood pressure measurements (lying, sitting, and standing) are recommended for patients experiencing dizziness, especially those on antihypertensive medications.
Question 7 of 9
Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next?
Correct Answer: C
Rationale: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6–12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.
Question 8 of 9
Which of the following is true of human papilloma virus (HPV) infection?
Correct Answer: B
Rationale: HPV is the most common STI in the United States and is by far the most common cause of cervical cancers. The sensitivity of the liquid-based cytology is between 61% and 95% and specificity is from 78% to 82%. While HPV affects almost 50% of the population at some point, many of these infections resolve spontaneously.
Question 9 of 9
A 50-year-old woman presents with a history of sudden-onset leg pain and swelling. She has a recent history of prolonged immobility due to a recent surgery. What is the most likely diagnosis?
Correct Answer: A
Rationale: Sudden-onset leg pain, swelling, and a history of recent immobility are consistent with deep vein thrombosis (DVT).