ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, 'I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!' Which of these responses by the nurse uses empathy?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Response C acknowledges the mother's feelings without judgment, showing understanding and empathy. 2. It validates her emotions by acknowledging the difficulty she is facing. 3. It does not assume or imply any specific emotion, allowing the mother to express herself freely. 4. Responses A and B are close but do not fully capture the depth of empathy displayed in response C. 5. Response D lacks empathy as it focuses more on agreement rather than truly understanding and validating the mother's emotions.
Question 2 of 5
The nurse is examining a school-age child. Which approach is best?
Correct Answer: B
Rationale: The correct answer is B because involving the child in the process and explaining equipment helps build trust, reduces anxiety, and promotes cooperation. This approach empowers the child, respects their autonomy, and facilitates a positive healthcare experience. Choice A is incorrect as rushing the examination may increase the child's anxiety. Choice C is incorrect as having a parent present can provide comfort and support. Choice D is incorrect as the focus should be on the child for effective assessment and communication.
Question 3 of 5
When assessing a patient's pulse, the nurse should also notice which of these characteristics?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Force of pulse indicates strength, reflecting cardiac output. 2. It is crucial to assess force to identify abnormalities like weak or bounding pulses. 3. Force helps in diagnosing conditions like heart failure or shock. 4. Pallor, capillary refill, and timing do not directly relate to pulse strength. Summary: A: Force is correct as it reflects cardiac output. B: Pallor is incorrect as it pertains to skin color. C: Capillary refill time is incorrect as it assesses peripheral perfusion. D: Timing in the cardiac cycle is incorrect as it focuses on heart rhythm.
Question 4 of 5
The nurse is performing a general survey of a patient. Which finding is considered normal?
Correct Answer: D
Rationale: The correct answer is D because arm span equaling the patient's height is considered normal. This is known as the ape index, where arm span is equal to height. This finding indicates proportional body development. A is incorrect as a narrow base when standing is abnormal. B is incorrect as appearing older than stated age is abnormal. C is incorrect as arm span greater than height can indicate abnormal growth or a medical condition.
Question 5 of 5
The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's:
Correct Answer: B
Rationale: The correct answer is B: Circulatory status. A thorough skin assessment is important as the skin provides valuable information on blood flow, oxygenation, and perfusion. Changes in skin color, temperature, and integrity can indicate circulatory issues like poor perfusion or compromised circulation. Understanding the circulatory status is crucial for identifying potential health problems and providing appropriate interventions. The other choices (A, C, D) are incorrect as they do not directly correlate with the primary purpose of a skin assessment, which is to evaluate the health of the circulatory system.