ATI RN
ATI Med Surg Health Assesment Quiz Questions
Extract:
Question 1 of 5
During an assessment the nurse performs the action shown in this image. What is the purpose of this action?
Correct Answer: C
Rationale: Pressing on the nail bed to assess capillary refill time evaluates peripheral perfusion, indicating circulatory status.
Question 2 of 5
After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)
Correct Answer: A,B,C,D,E
Rationale: All listed characteristics are essential for comprehensive documentation of lesions, providing critical information for diagnosis and monitoring.
Question 3 of 5
Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?
Correct Answer: B
Rationale: Silver sulfadiazine contains sulfa, and patients with sulfa allergies may experience allergic reactions, ranging from rashes to severe systemic responses.
Question 4 of 5
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
Correct Answer: A
Rationale: Mucous membranes are the best site to assess cyanosis in dark-skinned clients due to lower pigmentation and high vascularity.
Question 5 of 5
A 57-year-old client reports, 'I am having the worst headache I have ever experienced.' Which action/Priority should the nurse perform next?
Correct Answer: C
Rationale: Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.