ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem?
Correct Answer: B
Rationale: The correct answer is B: Optic nerve damage on the left. When both pupils dilate slightly but the right pupil constricts briskly when light is shone on it, it indicates an afferent defect in the left eye. The optic nerve carries afferent (sensory) signals from the eye to the brain. Since the left optic nerve is damaged, the afferent signal from the left eye is not transmitted properly, resulting in the dilated pupils. The brisk constriction of the right pupil in response to light indicates that the efferent (motor) pathway is intact on the right side. Therefore, the problem is likely on the afferent pathway of the left optic nerve. Incorrect choices: A: Optic nerve damage on the right - Incorrect because the brisk constriction of the right pupil indicates the efferent pathway on the right is intact. C: Efferent nerve damage on the right - Incorrect because the brisk constriction of the
Question 2 of 5
When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: Intracranial pressure 18 mm Hg. This is the most important information to communicate because changes in ICP can indicate increasing intracranial pressure, which can lead to serious complications such as brain herniation. Monitoring and promptly communicating any changes in ICP to the healthcare provider is crucial for timely intervention and prevention of further damage. Choice A: Oral temperature 102°F is important for assessing for signs of infection or inflammation, but it is not directly related to the intracranial pressure monitoring. Choice B: Apical pulse 102 beats/min is important for assessing cardiac function, but it is not directly related to intracranial pressure monitoring. Choice D: Mean arterial pressure 90 mm Hg is important for assessing perfusion to the brain, but it is not as directly relevant to intracranial pressure monitoring as the actual ICP reading itself.
Question 3 of 5
The nurse is assessing the adaptation of the client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
Correct Answer: D
Rationale: The correct answer is D because consistently using adaptive equipment in dressing shows successful adaptation to changes in functional status after a stroke. This indicates the client's acceptance of their limitations and willingness to use tools that enable independence. Choice A is incorrect as anger towards family is not a positive sign of adaptation. Choice B suggests emotional distress, which is not indicative of successful adaptation. Choice C indicates difficulty with using modified utensils, which is a sign of struggle rather than successful adaptation.
Question 4 of 5
What is the best way for the nurse to assess for clubbing of the fingers?
Correct Answer: B
Rationale: The correct answer is B - Check the angle of the nail bed. Clubbing is characterized by an increased angle (>180 degrees) between the nail bed and the skin. This is best assessed by looking at the nail bed directly. Inspecting for white spots (A), assessing for swelling in the fingertips (C), and observing the color of the nail beds (D) are not specific or accurate indicators of clubbing. Checking the angle of the nail bed is the most direct and reliable method to assess for clubbing of the fingers.
Question 5 of 5
During a musculoskeletal assessment, the nurse observes swelling and redness over a joint. What is the nurse's next action?
Correct Answer: A
Rationale: The correct answer is A: Assess the range of motion of the joint. This is the next action because swelling and redness over a joint can indicate inflammation or injury, which may affect the joint's mobility. Assessing the range of motion will help determine the extent of the issue and guide further interventions. Applying heat (B) may worsen inflammation, documenting as normal (C) is inappropriate given the abnormal findings, and referring for further evaluation (D) can be considered after assessing the range of motion to provide more specific information to the healthcare provider.