ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 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 2 of 5
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 3 of 5
What is the primary purpose of using a Doppler device during a physical examination?
Correct Answer: A
Rationale: Doppler devices are used to detect weak peripheral pulses when they are difficult to palpate.
Question 4 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a decreased range of motion in the knee joint. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Decreased range of motion in the knee joint is often a result of osteoarthritis, a condition characterized by the degeneration of joint cartilage.
Question 5 of 5
A pregnant woman states, 'I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor.' The nurse responds by stating, 'Oh, don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.' Which statement is true regarding this response? The nurse's reply was a:
Correct Answer: B
Rationale: By providing false assurance or reassurance, this courage builder relieves the woman's anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.