ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.
Correct Answer: C
Rationale: The correct answer is C: Recall; after a 30-minute delay. In the Four Unrelated Words Test, the individual is asked to recall four unrelated words after a brief delay. A 30-minute delay is crucial as it tests the individual's ability to retain and retrieve information from their long-term memory. If the individual struggles with this task, it may indicate potential memory impairment or cognitive decline. Choices A and B are incorrect as the test focuses on recall, not invention, and the time frame is typically longer than 5 minutes or 30 seconds. Choice D is incorrect as a 60-minute delay is too long for this specific test.
Question 2 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. Bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child indicate normal resonance due to increased air content in the lungs. This finding is consistent with normal lung sounds in children of this age. Palpating for pain or tenderness (choice A) is not indicated as the percussion findings are normal. Asking the child to take shallow breaths (choice B) would not change the percussion findings. Immediate referral (choice C) is unnecessary as the percussion findings are within the normal range for a child of this age.
Question 3 of 5
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Correct Answer: B
Rationale: The correct answer is B because giving feedback and reassurance during the examination is appropriate for a 4-year-old child. This approach helps to build trust, reduce anxiety, and make the child feel more comfortable. Providing reassurance also helps the child understand what is happening and promotes cooperation during the examination. Explanation for other choices: A: Explaining procedures in detail may overwhelm and increase anxiety in a 4-year-old child. C: Avoiding asking the child to remove clothing may hinder a thorough examination and compromise the child's health. D: Performing a head-to-toe examination starting with the ears may not be developmentally appropriate or engaging for a 4-year-old child.
Question 4 of 5
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
Correct Answer: C
Rationale: The correct answer is C. The tympanic method reduces the risk of cross-contamination compared to rectal temperature measurement. This is because the tympanic thermometer does not come into direct contact with mucous membranes or bodily fluids, unlike rectal thermometers. Cross-contamination can occur when pathogens are transmitted between individuals or surfaces. Therefore, using the tympanic method decreases the chances of spreading infections. Choice A is incorrect as tympanic temperature measurement is quicker compared to rectal temperature measurement. Choice B is incorrect as the tympanic method is non-invasive and generally well-tolerated. Choice D is incorrect as the tympanic membrane reflects the temperature of the blood vessels in the temporal artery, not the ophthalmic artery.
Question 5 of 5
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
Correct Answer: B
Rationale: The correct answer is B because auscultating an apical rate for 1 minute allows for a more accurate assessment of the infant's heart rate, which can vary. This method helps detect any abnormalities, such as sinus arrhythmia commonly seen in infants. Auscultating the apical rate is more accurate than palpating the radial pulse in infants due to their small size and delicate nature. Assessing blood pressure in infants requires specialized equipment, not just a stethoscope with a large diaphragm piece. Observing the chest for respiratory rate is important but does not provide a full assessment of vital signs.