ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
Correct Answer: A
Rationale: The correct technique is to count the radial pulse for 1 minute if the rhythm is irregular because irregular rhythms may have fluctuations that can affect accuracy. Counting for a full minute provides a more comprehensive assessment of the pulse rate. Choice B is incorrect because multiplying the count by 4 after 15 seconds may not accurately reflect the pulse rate if the rhythm is irregular. Choice C is incorrect because counting for 2 full minutes is unnecessary and can be time-consuming without providing additional benefits in most cases. Choice D is incorrect as multiplying by 6 after 10 seconds is not suitable for irregular rhythms or for patients with cardiac abnormalities.
Question 2 of 5
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
Correct Answer: A
Rationale: The correct answer is A. The woman's history of diabetes and peripheral vascular disease puts her at increased risk for infection and lesions when trying to remove the corn with scissors. Diabetes can impair wound healing and increase the risk of infection. Peripheral vascular disease can lead to poor circulation, further complicating wound healing. Choices B, C, and D are incorrect because they do not address the specific risks associated with the woman's chronic conditions. Choice B is incorrect as diabetes often causes poor circulation, not increased circulation. Choice C is incorrect as age and visual impairment are not the primary reasons for discouraging the use of scissors. Choice D is incorrect as it focuses on range of motion rather than the specific risks related to diabetes and peripheral vascular disease.
Question 3 of 5
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:
Correct Answer: A
Rationale: The correct answer is A: Tinea capitis. Tinea capitis is a fungal infection of the scalp that often presents with hair loss, scaling, and broken hair in patches. In this case, the patient's symptoms of hair loss, patchy scaling, and broken hair are consistent with tinea capitis. The nurse should suspect this diagnosis based on the clinical presentation. Other choices are incorrect because: B: Folliculitis typically presents with inflamed hair follicles, pustules, and redness. It is not characterized by patchy hair loss and scaling. C: Toxic alopecia is hair loss due to exposure to toxins or chemicals, which is not suggested by the symptoms described. D: Seborrheic dermatitis presents with greasy, yellowish scaling on the scalp, but typically does not cause patchy hair loss as described in the case.
Question 4 of 5
During an interview, the patient states he has the sensation that 'everything around him is spinning.' The nurse recognizes that the portion of the ear responsible for this sensation is the:
Correct Answer: D
Rationale: The correct answer is D: Labyrinth. The labyrinth is a structure in the inner ear that contains the vestibular system responsible for balance and spatial orientation. The sensation of spinning or vertigo is related to disturbances in the labyrinth. CN VIII, the vestibulocochlear nerve, carries information from the labyrinth to the brain. The cochlea (A) is responsible for hearing, not balance. The Organ of Corti (C) is a structure within the cochlea involved in hearing, not balance. Therefore, the correct choice is D as it directly relates to the sensation of spinning experienced by the patient.
Question 5 of 5
The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:
Correct Answer: C
Rationale: The correct answer is C because the presence of a crusty nodule that intermittently bleeds, does not heal, and has an ulcerated crusted appearance with an indurated base raises suspicion for potential carcinoma. This presentation is concerning for skin cancer, specifically a squamous cell carcinoma or basal cell carcinoma. Therefore, the patient should be referred for a biopsy to confirm the diagnosis and initiate appropriate treatment. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a painless, mobile, smooth nodule, a keloid (B) is characterized by an overgrowth of scar tissue and is not associated with the described symptoms, and a tophus (D) is a deposit of uric acid crystals seen in gout, which would present differently than the described ulcerated crusted nodule.