Vital Signs Assessment for Nurses

ATI RN · Vital Signs Assessment for Nurses

Question 1 of 62

The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

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ATI RN · Vital Signs Assessment for Nurses

Question 2 of 62

A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?

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ATI RN · Vital Signs Assessment for Nurses

Question 3 of 62

Scoliosis can be classified as structural or functional. Which one of the following is NOT a characteristic of structural scoliosis?

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ATI RN · Vital Signs Assessment for Nurses

Question 4 of 62

The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?

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ATI RN · Vital Signs Assessment for Nurses

Question 5 of 62

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

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ATI RN · Vital Signs Assessment for Nurses

Question 6 of 62

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

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ATI RN · Vital Signs Assessment for Nurses

Question 7 of 62

If a patient presents with a burn with damage to the epidermis but only partial damage to the dermis and has blistering, how is the burn classified?

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ATI RN · Vital Signs Assessment for Nurses

Question 8 of 62

A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have?

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ATI RN · Vital Signs Assessment for Nurses

Question 9 of 62

The respiratory rate is...

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ATI RN · Vital Signs Assessment for Nurses

Question 10 of 62

The physician order reads 'Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.' The patient's blood pressure is 92/66. The nurse does not give the medication and

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ATI RN · Vital Signs Assessment for Nurses

Question 11 of 62

The nurse is performing an otoscopic examination on a child and notes that the tympanic membrane is red and bulging. What condition does this finding suggest?

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ATI RN · Vital Signs Assessment for Nurses

Question 12 of 62

The most appropriate position in obtaining a rectal temperature for an adult would be:

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ATI RN · Vital Signs Assessment for Nurses

Question 13 of 62

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments?

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ATI RN · Vital Signs Assessment for Nurses

Question 14 of 62

A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

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ATI RN · Vital Signs Assessment for Nurses

Question 15 of 62

The nurse is assessing a patient's respiratory status and notes that the patient is using their neck muscles to breathe. What is the most likely cause of this finding?

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ATI RN · Vital Signs Assessment for Nurses

Question 16 of 62

A physical therapist evaluates a patient following a transtibial amputation. Which factor is MOST likely to contribute to knee instability during gait?

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ATI RN · Vital Signs Assessment for Nurses

Question 17 of 62

Before auscultating the abdomen for bowel sounds, the nurse should:

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ATI RN · Vital Signs Assessment for Nurses

Question 18 of 62

A physical therapist evaluates a patient with suspected carpal tunnel syndrome. Which clinical test is MOST appropriate to confirm the diagnosis?

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ATI RN · Vital Signs Assessment for Nurses

Question 19 of 62

The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?

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ATI RN · Vital Signs Assessment for Nurses

Question 20 of 62

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?

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ATI RN · Vital Signs Assessment for Nurses

Question 21 of 62

A physical therapist educates a patient on how to use a mechanical lift to transfer a family member from bed to a wheelchair. The therapist explains that the MOST important instruction for the caregiver is to:

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ATI RN · Vital Signs Assessment for Nurses

Question 22 of 62

A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection?

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ATI RN · Vital Signs Assessment for Nurses

Question 23 of 62

The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure?

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ATI RN · Vital Signs Assessment for Nurses

Question 24 of 62

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

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ATI RN · Vital Signs Assessment for Nurses

Question 25 of 62

The nurse is performing an abdominal assessment and notes that the patient has rebound tenderness. What is the most likely cause of this finding?

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ATI RN · Vital Signs Assessment for Nurses

Question 26 of 62

Sudden, painful unilateral loss of vision may be caused by which of the following conditions?

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ATI RN · Vital Signs Assessment for Nurses

Question 27 of 62

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

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ATI RN · Vital Signs Assessment for Nurses

Question 28 of 62

Which of the following findings during a respiratory assessment is considered abnormal?

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ATI RN · Vital Signs Assessment for Nurses

Question 29 of 62

Which contraction generates the least force?

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ATI RN · Vital Signs Assessment for Nurses

Question 30 of 62

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:

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ATI RN · Vital Signs Assessment for Nurses

Question 31 of 62

The nurse is performing a pain assessment and asks the patient to describe the location of their pain. Which dimension of pain is being assessed?

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ATI RN · Vital Signs Assessment for Nurses

Question 32 of 62

Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous?

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ATI RN · Vital Signs Assessment for Nurses

Question 33 of 62

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?

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ATI RN · Vital Signs Assessment for Nurses

Question 34 of 62

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?

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ATI RN · Vital Signs Assessment for Nurses

Question 35 of 62

Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:

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ATI RN · Vital Signs Assessment for Nurses

Question 36 of 62

A nurse is assessing a client's oxygen saturation level. What is the most common method used to measure oxygen saturation?

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ATI RN · Vital Signs Assessment for Nurses

Question 37 of 62

A 24-year-old travel agent comes to your clinic, complaining of pain and swelling in her vulvar area. She states that 2 days earlier she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago and she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum, a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems?

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ATI RN · Vital Signs Assessment for Nurses

Question 38 of 62

The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?

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ATI RN · Vital Signs Assessment for Nurses

Question 39 of 62

A woman is discussing the problems she is having with her 2-year-old son. She says, 'He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens.' The nurse's best verbal response would be:

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ATI RN · Vital Signs Assessment for Nurses

Question 40 of 62

You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.

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ATI RN · Vital Signs Assessment for Nurses

Question 41 of 62

A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured?

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ATI RN · Vital Signs Assessment for Nurses

Question 42 of 62

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:

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ATI RN · Vital Signs Assessment for Nurses

Question 43 of 62

During which phase of throwing is the elbow joint placed under the most valgus stress?

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ATI RN · Vital Signs Assessment for Nurses

Question 44 of 62

The nurse is assessing a patient's abdomen and notices rebound tenderness. What condition does this finding suggest?

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ATI RN · Vital Signs Assessment for Nurses

Question 45 of 62

The nurse is assessing a patient's mental status and observes that the patient is disoriented to time but oriented to person and place. How should this finding be documented?

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ATI RN · Vital Signs Assessment for Nurses

Question 46 of 62

During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?

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ATI RN · Vital Signs Assessment for Nurses

Question 47 of 62

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

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ATI RN · Vital Signs Assessment for Nurses

Question 48 of 62

A patient is taking medications to treat a heart arrhythmia. Which site should be used to assess pulse in this patient?

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ATI RN · Vital Signs Assessment for Nurses

Question 49 of 62

Which test is the most specific test to diagnose an ACL tear?

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ATI RN · Vital Signs Assessment for Nurses

Question 50 of 62

A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area?

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ATI RN · Vital Signs Assessment for Nurses

Question 51 of 62

During auscultation, the nurse hears an unfamiliar sound. The best action is to:

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ATI RN · Vital Signs Assessment for Nurses

Question 52 of 62

In a patient with acromegaly, the nurse will expect to discover which assessment findings?

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ATI RN · Vital Signs Assessment for Nurses

Question 53 of 62

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:

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ATI RN · Vital Signs Assessment for Nurses

Question 54 of 62

In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?

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ATI RN · Vital Signs Assessment for Nurses

Question 55 of 62

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

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ATI RN · Vital Signs Assessment for Nurses

Question 56 of 62

Hypothermia is defined as ...

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ATI RN · Vital Signs Assessment for Nurses

Question 57 of 62

Which of the following percussion notes would you obtain over the gastric bubble?

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ATI RN · Vital Signs Assessment for Nurses

Question 58 of 62

The nurse is assessing a patient's skin and notes a raised, rough lesion with a wart-like appearance. What is the most likely diagnosis?

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ATI RN · Vital Signs Assessment for Nurses

Question 59 of 62

You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial insufficiency. You perform the Allen test. This means that you:

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ATI RN · Vital Signs Assessment for Nurses

Question 60 of 62

A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?

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ATI RN · Vital Signs Assessment for Nurses

Question 61 of 62

A 40-year-old woman presents with a complaint of frequent urination and increased thirst. She reports that these symptoms have been present for several weeks. She has a family history of diabetes mellitus. What is the most likely diagnosis?

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ATI RN · Vital Signs Assessment for Nurses

Question 62 of 62

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:

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Practice results