Vital Signs Assessment for Nurses

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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?

  • A. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
  • B. Tonsils 2+/1-4+ with small plugs of white debris
  • C. Tonsils 3+/1-4+ with large white spots
  • D. Tonsils 3+/1-4+ with pale coloring
Correct Answer: C

Rationale: The correct answer is C because tonsils that are 3+/1-4+ with large white spots are indicative of exudative tonsillitis, which commonly occurs in acute bacterial infections like streptococcal pharyngitis. Here's the rationale:
1. Tonsils 3+ indicate significant enlargement, more than the normal size.
2. 1-4+ refers to the extent of the white spots or exudate present on the tonsils.
3. Large white spots suggest a substantial amount of exudate, commonly seen in bacterial infections like streptococcal pharyngitis.
Therefore, the presentation of enlarged tonsils with large white spots aligns with an acute bacterial infection.
Other choices are incorrect:
A: Tonsils are not significantly enlarged nor do they have white spots.
B: While there is white debris, it is not extensive as indicated by the 1-4+ scale.
D: Pale coloring does not indicate an

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

  • A. In an obese patient.
  • B. When part of the lung is obstructed or collapsed.
  • C. When bulging of the intercostal spaces is present.
  • D. When accessory muscles are used to augment respiratory effort.
Correct Answer: B

Rationale: The correct answer is B: When part of the lung is obstructed or collapsed. Unequal chest expansion can occur when there is an obstruction or collapse of a portion of the lung, leading to decreased lung expansion on that side. This can result in one side of the chest moving less during breathing. Other options are incorrect because: A: In an obese patient - obesity may affect chest wall movement but does not directly cause unequal chest expansion. C: When bulging of the intercostal spaces is present - bulging of intercostal spaces may indicate increased work of breathing but does not necessarily lead to unequal chest expansion. D: When accessory muscles are used to augment respiratory effort - while accessory muscles may be used in respiratory distress, they do not directly cause unequal chest expansion.

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

  • A. Heavy, flattened facial features
  • B. Growth retardation and a delayed onset of puberty
  • C. Overgrowth of bone in the face, head, hands, and feet
  • D. Increased height and weight and delayed sexual development
Correct Answer: C

Rationale: Rationale: Acromegaly is a condition caused by excessive growth hormone production, leading to overgrowth of bones in the face, head, hands, and feet. This results in characteristic features such as enlarged facial bones, hands, and feet. The correct answer is C because it aligns with the typical assessment findings in acromegaly.

Summary of other choices:
A (Heavy, flattened facial features): This is not consistent with acromegaly, as the condition is characterized by overgrowth of bone rather than flattened features.
B (Growth retardation and a delayed onset of puberty): These findings are more indicative of growth hormone deficiency rather than excess, which is seen in acromegaly.
D (Increased height and weight and delayed sexual development): While increased height and weight may occur, delayed sexual development is not a common feature of acromegaly.

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?

  • A. Alert and oriented to person and place, not time.
  • B. Disoriented to all spheres.
  • C. Alert but confused.
  • D. Fully oriented.
Correct Answer: A

Rationale: The correct answer is A because the patient is only disoriented to time, not person and place. Being alert and oriented to person and place but not time indicates a specific level of disorientation. Choice B is incorrect as the patient is not disoriented to all spheres. Choice C is incorrect as the patient is not confused but disoriented. Choice D is incorrect as the patient is not fully oriented due to being disoriented to time. Therefore, the correct documentation should accurately reflect the patient's state of being alert and oriented to person and place but not time.

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

  • A. Supine
  • B. Fowlers
  • C. Sims
  • D. Lateral
Correct Answer: C

Rationale: Sims, is correct because the Sims position (left lateral with upper leg flexed) provides optimal access to the rectum for temperature measurement in adults. It ensures patient comfort and safety while allowing the nurse to insert the probe accurately. Supine (lying flat on back), is impractical for rectal access. Fowlers (semi-sitting), is used for respiratory ease, not rectal procedures. Lateral (side-lying), is close but less specific than Sims, which includes leg positioning for better exposure. Rectal temperature, a core measurement, requires proper positioning to avoid discomfort or injury, and Sims is standard in clinical practice for its anatomical alignment, making C the most appropriate choice.

The respiratory rate is...

  • A. How many times an individual breaths in
  • B. How many times an individual breaths out
  • C. The number of breaths an individual takes in a minute
  • D. The oxygen saturation level
Correct Answer: C

Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.