ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
Which of the following is the most appropriate method for assessing skin turgor?
Correct Answer: B
Rationale: The correct answer is B: Pinching the skin over the sternum. Skin turgor is the skin's ability to return to its normal position after being pinched or pulled. The sternum is a central, flat bone that is less affected by factors like age or body fat distribution compared to other areas like the hands or abdomen. Pinching the skin over the sternum provides a more accurate assessment of skin turgor. Pinching the skin over the dorsum of the hand (A) may not be as reliable due to variations in skin thickness and elasticity. Pinching the skin over the forehead (C) and abdomen (D) are not ideal locations for assessing skin turgor as they are not commonly used for this purpose in clinical practice.
Question 2 of 5
A patient rehabilitating from a spinal cord injury is able to direct their own care but is dependent on others for all activities of daily living. The patient's injury would be classified as:
Correct Answer: A
Rationale: The correct answer is A: C4. This is because the patient is able to direct their own care, which indicates intact cognitive function, a characteristic of C4 spinal cord injury level. The patient being dependent on others for all activities of daily living suggests a high level of physical impairment, aligning with the functional limitations associated with C4 injury. Choices B, C, and D are incorrect as they represent higher spinal cord injury levels with varying degrees of upper extremity function and independence in self-care activities.
Question 3 of 5
A physical therapist observes a patient performing a deep squat. Which muscle group is MOST active during the ascent phase?
Correct Answer: A
Rationale: The hip extensors are most active during the ascent phase of a deep squat as they are responsible for extending the hip joint, which is required to stand up from the squat position. Knee flexors, ankle dorsiflexors, and trunk flexors are not primarily responsible for the movement pattern of ascending from a deep squat. Hip extensors play a crucial role in this phase by generating the necessary force to lift the body upright.
Question 4 of 5
A physical therapist examines a patient with a history of recurrent lateral ankle sprains. Which special test would BEST assess ligamentous integrity?
Correct Answer: A
Rationale: The correct answer is A: Anterior drawer test. This test assesses the integrity of the anterior talofibular ligament in the lateral ankle. Step 1: Stabilize the lower leg and move the ankle into slight dorsiflexion. Step 2: Grasp the calcaneus and apply an anterior force. Step 3: Positive test indicates excessive anterior translation, suggesting ligamentous laxity. Incorrect choices: B: Thompson test assesses Achilles tendon integrity, not ligamentous integrity. C: Talar tilt test assesses calcaneofibular and deltoid ligament integrity, not specifically lateral ligament. D: Kleiger test assesses syndesmotic ligament integrity, not lateral ligament.
Question 5 of 5
What is the best method for the nurse to assess for cyanosis in a dark-skinned patient?
Correct Answer: B
Rationale: The correct answer is B: Examine the lips and oral mucosa. In dark-skinned patients, cyanosis may not be easily visible on the skin. Lips and oral mucosa are more sensitive areas where cyanosis can be detected early. Inspecting the sclera (choice A) may not show cyanosis accurately. Palpating the skin for coolness (choice C) is not a specific method for detecting cyanosis. Assessing capillary refill in the fingers (choice D) is more related to circulation status rather than directly assessing for cyanosis.