ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 29 : Complementary and Integrative Health Questions
Question 1 of 5
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 (
B). Muffling (70) is phase IV, not standard for adults. 138/70 (
A) uses muffling incorrectly. 70/62 (
C) is invalid. 138/70/62 (
D) isn't standard.
Choice B is correct, per AHA guidelines.
Question 2 of 5
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?
Correct Answer: D
Rationale: Abnormally low BP requires verification and assessment. The nurse retaking it (
D) ensures accuracy and allows immediate patient evaluation, overriding NAP data. Retaking by NAP (
A) or adding vitals (
B) delays RN judgment. Ignoring it (
C) risks harm.
Choice D is correct, per RN accountability standards.
Question 3 of 5
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (
B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (
A) reflects cardiac response but isn't directly hypothalamic. Respirations (
C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (
D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here.
Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
Question 4 of 5
The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection (
C), where warm air around the body is replaced by cooler moving air. Radiation (
A) involves heat emission without contact, not fan-driven. Conduction (
B) requires direct contact (e.g., cold pack), not air movement. Evaporation (
D) involves moisture loss, not primarily fan-related here.
Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
Question 5 of 5
The patient has a temperature of 105.2?°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction (
B), transferring heat from the skin to the cooler objects through direct contact. Radiation (
A) involves heat loss to the environment without contact, not the primary method here. Convection (
C) requires air movement (e.g., fans), not used. Evaporation (
D) occurs with moisture vaporizing, a minor effect with tepid water but not dominant.
Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.