ATI RN
Vital Signs Assessment Quizlet Questions
Question 1 of 5
Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?
Correct Answer: C
Rationale: In a cardiac assessment of a 4-year-old child, the nurse would expect to notice a murmur at the second left intercostal space when the child is in a supine position (Option C) due to the presence of innocent murmurs common in children. This is the correct answer because innocent murmurs are frequently heard in pediatric populations and are typically benign, requiring no treatment or intervention. Option A (S3 when sitting up) is incorrect because S3 is not a common finding in children and is more indicative of heart failure in adults. Option B (Persistent tachycardia above 150 beats per minute) is incorrect as a heart rate above 150 bpm is abnormal in a 4-year-old child. Option D (Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line) is incorrect because a palpable apical impulse in this location is more typical of an adult and not a child. Educationally, it is important for healthcare professionals to understand the normal variations in pediatric vital signs and assessments to differentiate between benign findings and those that require further investigation or intervention. Recognizing innocent murmurs in children helps prevent unnecessary anxiety for parents and unnecessary testing or treatment for the child.
Question 2 of 5
A patient complains of leg pain that wakes him at night. He states that he 'has been having problems' with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed 'a sore' on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:
Correct Answer: B
Rationale: The correct answer is B) Problems related to arterial insufficiency. In this scenario, the patient's symptoms suggest a possible peripheral arterial disease. The leg pain that is worse at night and improves when dangling the legs is indicative of decreased blood flow to the lower extremities when elevated, a classic symptom of arterial insufficiency. The presence of a sore on the inner aspect of the right ankle further supports this diagnosis as it could be an ulcer due to poor circulation. Option A) Pain related to lymphatic abnormalities is incorrect as the symptoms described are more consistent with arterial rather than lymphatic issues. Option C) Problems related to venous insufficiency typically present with symptoms like edema, varicose veins, and pain that worsens when standing for long periods, which are not evident in this case. Option D) Pain related to musculoskeletal abnormalities does not fit the patient's symptoms of worsening pain with leg elevation and improvement with dangling, along with the presence of an ulcer. Understanding how to differentiate between arterial and venous insufficiency based on patient history is crucial for nurses in assessing and managing patients with potential circulatory issues. Recognizing these subtle differences can lead to timely interventions and prevent further complications.
Question 3 of 5
During a routine office visit, a patient takes off his shoes and shows the nurse 'this awful sore that won't heal.' On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Arterial ischemic ulcer. The key indicators for this type of ulcer include a pale ischemic base, well-defined edges, and no drainage, which align with the description of the ulcer on the patient's toe. Arterial ischemic ulcers typically occur due to poor blood circulation, often associated with conditions like peripheral artery disease. Option A) Varicosities refers to enlarged, twisted veins usually seen in the legs, but they do not typically present as ulcers like the one described. Option B) Venous stasis ulcer is associated with venous insufficiency and commonly presents with irregular wound edges and may have drainage. Option D) Deep-vein thrombophlebitis involves a blood clot in a deep vein and presents with swelling, redness, and warmth along the affected vein rather than an ulcer. Understanding the characteristics of different types of ulcers is crucial for nurses to provide appropriate care and interventions. Recognizing the specific signs and symptoms helps in accurate diagnosis and timely treatment to prevent complications and promote healing. This case highlights the importance of thorough assessment and knowledge of various wound etiologies in clinical practice.
Question 4 of 5
You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of:
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Cheyne-Stokes respiration. Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by shallow, slow breathing and apnea. This pattern is often seen in patients with heart failure, brain injuries, or other conditions affecting the respiratory centers in the brain. The patient's lack of distress despite the abnormal breathing pattern is a key characteristic of Cheyne-Stokes respiration. Option A) Ataxic (Biot's) breathing is characterized by unpredictable irregularity in the depth and rate of breathing, often seen in patients with brain injuries. This does not match the described pattern of deepening and shallowing breaths. Option C) Kussmaul's respiration is deep, rapid, and labored breathing often seen in patients with metabolic acidosis. This pattern does not align with the described breathing pattern in the patient with heart failure. Option D) COPD with prolonged expiration would not present with the described pattern of progressively deeper and shallower breaths followed by apnea. COPD typically presents with prolonged expiration due to air trapping in the lungs. Understanding and recognizing abnormal breathing patterns like Cheyne-Stokes respiration is crucial for healthcare providers to appropriately assess and manage patients with respiratory compromise. By differentiating between these patterns, healthcare professionals can provide timely and effective interventions to support patient respiratory function and overall well-being.
Question 5 of 5
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. a. Blood pressure 74/50, HR 148
Correct Answer: A
Rationale: In this scenario, the correct answer is A) First-level priority. The reason for this is that the patient's vital signs indicate a critical situation requiring immediate attention. A blood pressure of 74/50 and a heart rate of 148 suggest hypotension and tachycardia, which could indicate a life-threatening condition such as shock. Choosing option B) Second-level priority would be incorrect because vital signs as abnormal as these require immediate intervention to stabilize the patient before addressing other less urgent issues. Option C) Third-level priority is also incorrect because waiting to address the critically abnormal vital signs could result in deterioration of the patient's condition and potential harm. From an educational standpoint, understanding how to prioritize patient care based on the urgency of the situation is crucial in healthcare. Recognizing and responding to abnormal vital signs promptly can make a significant difference in patient outcomes. This question highlights the importance of recognizing first-level priority problems that require immediate action to ensure patient safety and well-being.