ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 29 Questions
Question 1 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 2 of 5
The patient with heart failure is restless with a temperature of 102.2?°F (39?°C). Which action will the nurse take?
Correct Answer: A
Rationale: Heart failure with fever (102.2?°F) and restlessness suggests increased oxygen demand. Applying oxygen (
A) addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing (
B) is irrelevant without respiratory symptoms. Restricting fluids (
C) may worsen dehydration in fever. Increasing metabolic rate (
D) exacerbates stress.
Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.
Question 3 of 5
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
Correct Answer: C
Rationale: In deteriorating patients, carotid (
C) provides a strong, accessible pulse, reliable even in low perfusion, unlike radial (
A) or brachial (
B). Popliteal (
D) is impractical.
Choice C is correct, per emergency nursing standards (e.g., AH
A), for critical pulse checks.
Question 4 of 5
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
Correct Answer: A
Rationale: Temperature varies by route (
A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (
B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect).
Choice A is correct, per nursing documentation standards.
Question 5 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.