ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B) When the patient first noticed the lesion. This information is crucial for the nurse to assess because the timing of when the patient first noticed the lesion can provide valuable insights into the potential cause of the ulceration. For example, if the patient recently experienced trauma to the lip or had a known exposure to a potential irritant, this could explain the presence of the ulceration. Option A) Nutritional status may be important in the overall assessment of the patient's health but is not directly relevant to the specific assessment of the ulceration on the lip. Option C) Whether the patient has had a recent cold is not as pertinent to the assessment of the mouth ulceration unless there is a suspected connection between the two. Option D) Whether the patient has had any recent exposure to sick animals is not directly related to the assessment of the mouth ulceration and would not provide as much pertinent information as knowing when the patient first noticed the lesion. Educationally, this question highlights the importance of thorough assessment and the significance of gathering detailed information to aid in making accurate clinical judgments and providing appropriate care to patients. Understanding the context and timing of symptoms is crucial in nursing assessments to establish a comprehensive picture of the patient's health status.
Question 2 of 5
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
Correct Answer: B
Rationale: With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.
Question 3 of 5
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States?
Correct Answer: C
Rationale: Black women have a higher mortality rate from breast cancer than white women and are more likely to die of their disease. In addition, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortality rates may be related to an insufficient use of screening measures and a lack of access to health care.
Question 4 of 5
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: In this question, the correct answer is C) Aortic and pulmonic. When listening to heart sounds, the nurse can hear the aortic and pulmonic valve closures best at the base of the heart. This is because these valves are located at the base of the heart where the major blood vessels exit. The aortic valve is on the left side, and the pulmonic valve is on the right side at the base of the heart. Option A) Mitral and tricuspid is incorrect because these valves are located at the apex of the heart and are best heard at the lower left sternal border. Option B) Tricuspid and aortic is incorrect because the tricuspid valve is best heard at the lower left sternal border along the tricuspid area. Option D) Mitral and pulmonic is incorrect because the mitral valve is best heard at the apex of the heart, while the pulmonic valve is best heard at the left upper sternal border. Understanding the specific locations of the heart valves and where they are best auscultated is crucial for accurate assessment and diagnosis of cardiac conditions. By knowing where to listen for each valve, nurses can detect abnormalities and provide appropriate care to their patients.
Question 5 of 5
While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?
Correct Answer: B
Rationale: In this scenario, option B is the correct interpretation of the findings. It is crucial to understand that children often exhibit innocent murmurs, which are common and considered normal variations. An S3 sound can also be normal in children due to the compliant nature of their ventricles. The venous hum heard when the child is standing is likely due to increased blood flow in the jugular vein, which is a normal finding. Option A is incorrect because an S3 sound alone does not necessarily indicate heart disease in children. Option C is incorrect as these findings do not specifically point to congenital problems. Option D is incorrect as a venous hum does not indicate an aneurysm. In an educational context, it is essential for healthcare providers to be aware of the variations in normal findings in pediatric patients to prevent unnecessary alarm or further testing. Understanding the nuances of pediatric auscultation helps in accurate diagnosis and appropriate management of children's health conditions.