Vital Signs Assessment for Nurses

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

  • A. Positioning the patient's arm above the level of the heart.
  • B. Using a cuff that covers two-thirds of the patient's upper arm.
  • C. Deflating the cuff at a rate of 5-10 mm Hg per second.
  • D. Having the patient stand during the measurement.
Correct Answer: B

Rationale: The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement.

A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results.
C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size.
D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.

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

  • A. Cholecystitis.
  • B. Peritonitis.
  • C. Appendicitis.
  • D. Diverticulitis.
Correct Answer: B

Rationale: Rebound tenderness, where pain worsens upon releasing pressure, is a sign of peritonitis, inflammation of the abdominal lining. This suggests an urgent medical issue involving the peritoneum. Cholecystitis (A) is inflammation of the gallbladder, not the peritoneum. Appendicitis (C) involves the appendix, not the peritoneum. Diverticulitis (D) is inflammation of diverticula in the colon, not the peritoneum. Peritonitis is the correct answer due to the specific association of rebound tenderness with peritoneal inflammation.

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?

  • A. flat
  • B. dull
  • C. resonant
  • D. tympany
Correct Answer: D

Rationale: Tympany , per the answer key, is the hollow, drum-like tone over the air-filled stomach. Flat is over bone, dull organs, resonant lungs. Nurses, per Taylor, expect tympany in gastric percussion for normal assessment.

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

  • A. Pivot shift
  • B. Lachman test
  • C. Anterior drawer sign
  • D. Ege's test
Correct Answer: A

Rationale: The correct answer is A: Pivot shift. This test is the most specific for diagnosing an ACL tear because it assesses the rotational instability of the knee joint, which is a key characteristic of an ACL injury. During the test, the examiner applies a valgus force and internal rotation to the knee while extending it, causing the tibia to subluxate anteriorly. If there is an ACL tear, the tibia will suddenly reduce back into place, producing a characteristic "pivot shift" movement.

Summary of other choices:
B: Lachman test - While also used to assess ACL integrity, it primarily evaluates anterior translation of the tibia and is not as specific for rotational instability.
C: Anterior drawer sign - This test is primarily used to assess anterior translation of the tibia and is not specific to diagnosing an ACL tear.
D: Ege's test - This test is not commonly used in clinical practice for diagnosing ACL tears.

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.

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:

  • A. The woman could be at increased risk for infection and lesions because of her chronic disease.
  • B. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding.
  • C. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors.
  • D. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.
Correct Answer: A

Rationale: The correct answer is A. The woman's history of diabetes and peripheral vascular disease puts her at increased risk for infection and lesions when trying to remove the corn with scissors. Diabetes can impair wound healing and increase the risk of infection. Peripheral vascular disease can lead to poor circulation, further complicating wound healing. Choices B, C, and D are incorrect because they do not address the specific risks associated with the woman's chronic conditions. Choice B is incorrect as diabetes often causes poor circulation, not increased circulation. Choice C is incorrect as age and visual impairment are not the primary reasons for discouraging the use of scissors. Choice D is incorrect as it focuses on range of motion rather than the specific risks related to diabetes and peripheral vascular disease.