ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The true leg length should be measured between which of the following points?
Correct Answer: C
Rationale: The true leg length should be measured between the ASIS (anterior superior iliac spine) and the medial malleolus. This is because the ASIS is a prominent bony landmark on the pelvis, representing the top of the femur, and the medial malleolus is the bony prominence on the inner side of the ankle, representing the bottom of the tibia. Measuring between these points provides an accurate representation of the actual length of the leg. Choice A (Greater trochanter to lateral malleolus) is incorrect because the greater trochanter is not the starting point for measuring leg length. Choice B (Umbilicus and lateral malleolus) is incorrect as the umbilicus is not a reliable reference point for leg length measurement. Choice D (Anterior inferior iliac spine and medial malleolus) is incorrect because the AIIS is not typically used as a reference point for leg length measurement.
Question 2 of 5
If a burn patient is splinted in a comfortable position for grafted burns to heal, the patient is at risk for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Wound contracture. When a burn patient is splinted in a comfortable position for grafted burns to heal, there is a risk of wound contracture due to prolonged immobility. Wound contracture refers to the tightening and shrinking of the skin and underlying tissues, leading to restricted joint movement and functional impairment. This complication can result in long-term disability and decreased quality of life for the patient. Choices A, B, and C are incorrect: A: Tendon rupture is not a typical complication of splinting a burn patient in a comfortable position. B: Skin breakdown may occur if the splint is too tight or if there is excessive pressure on certain areas, but it is not the primary risk associated with this scenario. C: Mechanical falls are unrelated to the positioning of the burn patient for graft healing.
Question 3 of 5
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that require attention after addressing first-level problems but before third-level problems. Abnormal laboratory values fall into this category because they may indicate a potential for worsening health conditions if left untreated. Low self-esteem (choice A) is typically a third-level priority, lack of knowledge (choice B) can usually be addressed as a lower priority, and severely abnormal vital signs (choice D) are considered first-level priorities due to their immediate threat to the patient's well-being.
Question 4 of 5
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
Correct Answer: D
Rationale: The correct answer is D because a 2.5 cm scar on the right lower forearm is an observable and measurable physical finding. Objective information in a physical assessment is data that can be directly observed or measured by the healthcare provider. Scars are physical characteristics that can be visually confirmed, making them objective. Choices A, B, and C are subjective information as they rely on the patient's report or history, which may be influenced by memory, perception, or interpretation. Therefore, they are not considered objective data.
Question 5 of 5
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
Correct Answer: C
Rationale: The correct answer is C, a complete health data base. In this initial home visit for a patient with chronic medical problems, the nurse's primary responsibility is to gather comprehensive information about the patient's health status, medical history, current medications, social support, and lifestyle factors. This type of data base allows for a holistic assessment and forms the foundation for ongoing care planning and monitoring. Choice A is incorrect because a follow-up data base is not suitable for an initial visit as it focuses on evaluating changes over time. Choice B is incorrect as an episodic data base is more appropriate for acute, single-issue visits. Choice D is incorrect as an emergency data base is used in urgent situations requiring rapid assessment and treatment, not for a routine initial visit for chronic medical problems.