Vital Signs Assessment

Vital Signs Assessment Related

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A client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

  • A. Side-lying, with a pillow under the hip.
  • B. Prone, with a pillow under the abdomen.
  • C. Prone, in slight-Trendelenburg's position.
  • D. Side-lying, with the legs pulled up and head bent down onto chest.
Correct Answer: D

Rationale: The correct answer is D. During a lumbar puncture, the client should be positioned in a side-lying position with the legs pulled up and head bent down onto the chest. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to access the lumbar area. Placing the legs up also helps to widen the spaces between the vertebrae, making it easier to insert the needle without damaging the spinal cord. The head bent down onto the chest helps to round the back, further increasing the space between the vertebrae.

Choice A is incorrect because placing a pillow under the hip does not provide the necessary positioning for a lumbar puncture. Choice B is incorrect as the prone position with a pillow under the abdomen would not facilitate access to the lumbar area. Choice C is incorrect as the Trendelenburg's position is not recommended for lumbar punctures as it can increase intracranial pressure.

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When using an otoscope to examine a patient, the nurse:

  • A. Uses a broad speculum to visualize sinuses.
  • B. Examines the inner ear structures.
  • C. Directs light onto the tympanic membrane.
  • D. Checks for external lesions with the light.
Correct Answer: C

Rationale: The correct answer is C because when using an otoscope, the nurse should direct light onto the tympanic membrane (eardrum) to visualize its condition. This helps in assessing ear health and identifying any abnormalities or infections. Choice A is incorrect as an otoscope is not used to visualize sinuses. Choice B is incorrect as it refers to examining inner ear structures which is beyond the scope of an otoscope. Choice D is incorrect as external lesions are not typically assessed using an otoscope.

The nurse is performing a neurological assessment and notes a positive Romberg test. What does this finding indicate?

  • A. Cranial nerve dysfunction.
  • B. Cerebellar ataxia or vestibular dysfunction.
  • C. Peripheral neuropathy.
  • D. Increased intracranial pressure.
Correct Answer: B

Rationale: The Romberg test assesses balance and postural stability. A positive Romberg test indicates a deficit in proprioception, which is commonly seen in cerebellar ataxia or vestibular dysfunction. The cerebellum and vestibular system play crucial roles in maintaining balance and coordination. Cranial nerve dysfunction (A) does not directly affect balance. Peripheral neuropathy (C) primarily affects sensation and motor function, not balance. Increased intracranial pressure (D) may present with other neurological signs, but not specifically a positive Romberg test. Therefore, the correct answer is B.

Which of the following is the medically acute inpatient cardiac rehabilitation phase?

  • A. Phase 1
  • B. Phase 2
  • C. Phase 3
  • D. Phase 4
Correct Answer: A

Rationale: The correct answer is A: Phase 1. This phase is the medically acute inpatient cardiac rehabilitation phase focused on initial evaluation, stabilization, and education post-cardiac event. Phase 2 involves early outpatient exercise and education, Phase 3 is the maintenance phase, and Phase 4 is long-term independent exercise. Phase 1 is crucial for monitoring and managing acute cardiac issues, making it the correct choice.

Which of the following findings is most concerning during a peripheral vascular assessment?

  • A. Capillary refill time of 2 seconds.
  • B. Equal pulses bilaterally.
  • C. Unilateral edema.
  • D. Warm skin temperature in both extremities.
Correct Answer: C

Rationale: The correct answer is C, unilateral edema. This finding is most concerning as it may indicate a blockage or dysfunction in the lymphatic or venous system, potentially leading to serious conditions like deep vein thrombosis. In contrast, A and D are normal findings indicating good peripheral circulation, while B is also normal and indicates balanced blood flow.

The cruciate ligaments of the knee lie in which of the following locations?

  • A. Inside the joint capsule and synovial cavity
  • B. Outside the synovial cavity but within the fibrous joint capsule
  • C. Outside the fibrous joint capsule
  • D. Outside both the synovial and fibrous joint capsules
Correct Answer: B

Rationale: The correct answer is B: Outside the synovial cavity but within the fibrous joint capsule. The cruciate ligaments of the knee are located within the joint capsule, which is a fibrous structure surrounding the knee joint. They are positioned outside the synovial cavity, which is the space within the joint capsule that contains synovial fluid. This location allows the cruciate ligaments to provide stability to the knee joint without being directly exposed to the synovial fluid. Choices A, C, and D are incorrect because they do not accurately describe the specific location of the cruciate ligaments within the knee joint.