Which groups body temperature changes more rapidly in response to both heat and cold air temperatures?
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HESI RN · ATI Vital Signs Assessment
Question 2 of 64
The blood pressure is...
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Question 3 of 64
A grandmother brings her 13-year-old grandson for evaluation of a collapsed breastbone that has been present for quite awhile. He has no symptoms but is embarrassed about his appearance.
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Question 4 of 64
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
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Question 5 of 64
Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?
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Question 6 of 64
A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patients blood pressure is 90/50. What is the name for this condition?
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Question 7 of 64
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. Which component is not included in this scale?
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Question 8 of 64
A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?
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Question 9 of 64
A monophasic, high-pitched sound usually caused by partial obstruction in the upper airway is called which of the following?
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Question 10 of 64
A 40-year-old man presents with abdominal pain and vomiting. He has a history of alcohol use and liver disease. On examination, he has jaundice and ascites. His serum bilirubin is elevated, and liver function tests show elevated AST and ALT. Which of the following is the most likely diagnosis?
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Question 11 of 64
The nurse is performing an assessment. Which of these findings would cause the greatest concern?
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Question 12 of 64
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
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Question 13 of 64
A 29-year-old married computer programmer comes to your clinic, complaining of 'something strange' going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis?
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Question 14 of 64
During an eye assessment, the nurse observes that the patient's pupils constrict when focusing on a near object. What is this response called?
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Question 15 of 64
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
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Question 16 of 64
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?
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Question 17 of 64
A client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
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Question 18 of 64
When teaching a client how to effectively manage their new medication regimen, the nurse recognizes that the best method of communicating therapeutically with the client is to:
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Question 19 of 64
The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity?
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Question 20 of 64
Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient?
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Question 21 of 64
A 60-year-old man presents with difficulty swallowing. He has a history of smoking and chronic alcohol use. He also reports weight loss and a hoarse voice. What is the most likely diagnosis?
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Question 22 of 64
The nurse is assessing cranial nerve XI (spinal accessory nerve). Which action is most appropriate?
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Question 23 of 64
During an acute episode of dyspnea in chronic obstructive pulmonary disease (COPD) patients, which breathing technique may help to reduce symptoms and the work of breathing?
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Question 24 of 64
A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
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Question 25 of 64
The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?
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Question 26 of 64
A nurse is assessing a client's respiratory rate and finds it to be irregular, with periods of deep breaths alternating with shallow breaths. What action should the nurse take?
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Question 27 of 64
A rise of 1-degree Fahrenheit of temperature will increase the pulse rate by how many beats per minute?
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Question 28 of 64
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
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Question 29 of 64
The nurse is assessing a patient's respiratory system and notes the presence of stridor. What does this finding most likely indicate?
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Question 30 of 64
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling?
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Question 31 of 64
Which of the following patients would be an appropriate candidate for the use of a radiant heater?
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Question 32 of 64
In which of the following areas could microwave diathermy be used?
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Question 33 of 64
The nurse is assessing a patient's cranial nerve function and asks the patient to raise both eyebrows. Which cranial nerve is being tested?
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Question 34 of 64
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
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Question 35 of 64
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
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Question 36 of 64
A 50-year-old man with a history of heavy alcohol use presents with abdominal pain, jaundice, and ascites. His serum bilirubin is elevated, and liver function tests show elevated AST and ALT. What is the most likely diagnosis?
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Question 37 of 64
The popliteus muscle performs an important action of unlocking the knee by which mechanism?
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Question 38 of 64
A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?
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Question 39 of 64
The nurse is assessing a patient's hearing using the Weber test. How is this test performed?
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Question 40 of 64
A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
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Question 41 of 64
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:
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Question 42 of 64
Which cranial nerve is being tested when the nurse asks the patient to stick out their tongue?
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Question 43 of 64
If a patient is supine with knees flexed to 90 degrees and feet flat on the table, how will it be determined if the right femur is longer than the left?
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Question 44 of 64
The nurse is assessing a patient's pupils and notes that the pupils constrict when exposed to light but do not constrict when focused on a near object. What does this finding suggest?
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Question 45 of 64
During a cardiovascular assessment, the nurse auscultates a murmur that occurs during diastole. What is the most likely cause of this finding?
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Question 46 of 64
A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?
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Question 47 of 64
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature?
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Question 48 of 64
The nurse is assessing a patient's lungs and hears wheezing on expiration. What condition is most likely associated with this finding?
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Question 49 of 64
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next?
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Question 50 of 64
A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active and has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high blood pressure. She is widowed and has three children. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae. What vaginitis does this patient most likely have?
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Question 51 of 64
Which physical assessment finding is most indicative of fluid volume overload?
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Question 52 of 64
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
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Question 53 of 64
What is the correct technique for assessing the carotid arteries?
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Question 54 of 64
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
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Question 55 of 64
When using assessment equipment that will touch the patient, what should the nurse do before conducting the assessment?
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Question 56 of 64
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:
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Question 57 of 64
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
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Question 58 of 64
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
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Question 59 of 64
Which finding during a neurological assessment suggests damage to cranial nerve VIII (vestibulocochlear nerve)?
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Question 60 of 64
The nurse is assessing a patient's skin. Which technique should be used to best assess skin temperature?
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Question 61 of 64
The nurse asks, 'I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.' This question is found at the _____ phase of the interview process.
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Question 62 of 64
How do you measure for leg length discrepancy?
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Question 63 of 64
A 55-year-old woman presents with a complaint of a lump in her breast. On examination, a firm, non-mobile mass is palpated in the upper outer quadrant of the left breast. What is the most appropriate next step in the management of this patient?
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Question 64 of 64
Dakota is a 14-year-old boy who just noticed a rash at his ankles. There is no history of exposure to ill people or other agents in the environment. He has a slight fever in the office. The rash consists of small, bright red marks. When they are pressed, the red colour remains. What should you do?
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