ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
Correct Answer: C
Rationale: The correct answer is C: Systolic blood pressure may be falsely low. An auscultatory gap is a silent interval between the Korotkoff sounds during blood pressure measurement, commonly seen in hypertension. If the nurse does not check for an auscultatory gap, they may miss this silent interval, leading to an underestimation of the systolic blood pressure. Choices A and B are incorrect because missing an auscultatory gap does not affect the ability to hear diastolic blood pressure or result in a falsely low diastolic reading. Choice D is incorrect as missing an auscultatory gap would not lead to a falsely high systolic blood pressure.
Question 2 of 5
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this scenario, the presence of bilateral pitting edema in a patient with a history of hypertension and coronary artery disease suggests fluid overload due to heart failure. The puffy and tight skin without redness or tenderness indicates the edema is non-inflammatory. Equal and strong peripheral pulses suggest good circulation, ruling out venous thrombosis. Absence of signs like redness, warmth, or pain in the legs excludes local inflammation. Blockage of lymphatic drainage typically presents with unilateral edema and is less common in this patient population. Therefore, given the patient's history and physical findings, heart failure is the most likely cause of the bilateral pitting edema.
Question 3 of 5
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:
Correct Answer: A
Rationale: The correct answer is A: Otosclerosis. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, specifically the stapes bone. This abnormal bone growth can lead to conductive hearing loss, which may result in the patient experiencing progressive hearing loss. In this case, the patient's symptoms of hearing improvement with louder sounds or increased volume suggest a conductive hearing loss, which is common in otosclerosis. Choice B: Presbycusis, is age-related hearing loss and typically presents as a gradual decline in hearing over time, not necessarily with a sudden progressive loss as described in the scenario. Choice C: Trauma to the bones would likely result in a more sudden onset of hearing loss, not a progressive loss as described in the scenario. Choice D: Frequent ear infections may lead to temporary hearing loss due to fluid buildup or damage to the ear structures, but the symptoms described in the scenario are more indicative of a chronic condition like otosclerosis.
Question 4 of 5
The projections in the nasal cavity that increase the surface area are called the:
Correct Answer: C
Rationale: The correct answer is C: Turbinates. Turbinates are bony projections in the nasal cavity that increase surface area for warming, humidifying, and filtering air. Meatus (A) refers to the openings in the nasal cavity, septum (B) is the cartilage dividing the nostrils, and Kiesselbach plexus (D) is a vascular area in the anterior nasal septum. These choices are incorrect as they do not specifically refer to the structures that increase surface area in the nasal cavity.
Question 5 of 5
The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left nares. This is the correct next step to further assess the purulent drainage with a foul odor. By performing an otoscopic examination, the nurse can visualize the nasal passage and identify any underlying issues such as a possible foreign body, infection, or inflammation. It is important to rule out any potential serious conditions that may require medical intervention. Choice A is incorrect because antibiotics should not be prescribed without a proper assessment and diagnosis. Choice B is incorrect as waiting for a week can potentially lead to worsening of the condition. Choice D is incorrect as purulent drainage with a foul odor is not normal and should be further investigated.