ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should:
Correct Answer: D
Rationale: The correct answer is D. A tripod position, where a patient leans forward with arms braced on a chair, is often used when a patient is having respiratory difficulties, such as in asthma exacerbation. This position helps improve airflow by allowing better expansion of the chest. The patient is likely trying to relieve breathing difficulty by maximizing lung expansion. Choosing option D is appropriate as it acknowledges the significance of the tripod position in respiratory distress. A: This choice is incorrect because assuming the patient is eager and interested in participating in the interview does not relate to the observation of the tripod position in a patient with asthma. B: Evaluating the patient for abdominal pain is not the priority in this scenario where respiratory distress is suspected. C: This option is incorrect as moving the patient to a supine position may worsen breathing difficulties.
Question 2 of 5
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
Correct Answer: A
Rationale: Step 1: Identify the patient's symptom - excessive dryness of the skin. Step 2: Recall the term for this condition - xerosis, characterized by dry skin. Step 3: Eliminate other choices - pruritus means itching, alopecia refers to hair loss, seborrhea is excessive oiliness. Step 4: Confirm xerosis as the best fit due to matching symptomatology. Step 5: Choose option A as the correct answer for precise description of the patient's condition.
Question 3 of 5
A patient has had a 'terrible itch' for several months that he has been continuously scratching. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: Lichenification. Lichenification is a skin condition characterized by thickening and hardening of the skin due to chronic irritation or scratching. In this case, the patient's continuous scratching of the itch has led to lichenification. This is evident by the rough and leathery texture of the skin upon examination. A: A keloid is an overgrowth of scar tissue that can occur after a wound heals, not typically associated with chronic scratching. B: A fissure is a small, painful crack in the skin that can occur due to dryness or trauma, not a result of continuous scratching. C: Keratosis refers to various skin conditions characterized by thickening of the skin, but it is not specifically associated with chronic scratching like lichenification. In summary, lichenification is the most likely finding in this scenario due to the chronic scratching leading to skin thickening and hardening.
Question 4 of 5
A patient with a middle ear infection asks the nurse, 'What does the middle ear do?' The nurse responds by telling the patient that the middle ear functions to:
Correct Answer: C
Rationale: The correct answer is C: Conduct vibrations of sounds to the inner ear. The middle ear consists of the eardrum and three small bones that transmit sound vibrations from the eardrum to the inner ear. This process allows sound waves to be converted into electrical signals that can be interpreted by the brain. Choice A is incorrect because balance is primarily controlled by structures in the inner ear, not the middle ear. Choice B is incorrect as interpreting sounds happens in the inner ear and brain, not the middle ear. Choice D is incorrect because the middle ear does not increase the amplitude of sound; rather, it amplifies and transmits sound vibrations to the inner ear for further processing.
Question 5 of 5
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):
Correct Answer: B
Rationale: The correct answer is B: Acute otitis media. In this case, the bright red tympanic membrane and the absence of the light reflex suggest inflammation and infection of the middle ear, which are characteristic of acute otitis media. The child's symptoms of pulling on his ear also support this diagnosis. A: Fungal infection typically presents with white patches and not necessarily redness or absence of light reflex. C: Perforation of the eardrum would show a visible hole in the tympanic membrane. D: Cholesteatoma is a noncancerous growth that would present differently on otoscopic examination.