ATI RN
Assess Vital Signs Questions
Question 1 of 5
A 75-year-old retired teacher presents with severe, unrelenting anterior chest pain radiating to her back, described as 'ripping out her heart.' Blood pressure is 180/110 in the right arm and 130/60 in the left arm, with asymmetric carotid pulses.
Correct Answer: C
Rationale: The correct answer is C: Dissecting aortic aneurysm. The patient's presentation is consistent with aortic dissection due to severe chest pain radiating to the back, asymmetric blood pressure in both arms, and asymmetric pulses. Aortic dissection is a life-threatening emergency requiring immediate intervention. Angina pectoris typically does not present with asymmetric blood pressure or pulses. Pericarditis usually presents with chest pain that worsens with deep breathing and is relieved by sitting up. Pleural pain is typically localized and not associated with asymmetric blood pressure or pulses.
Question 2 of 5
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
Correct Answer: C
Rationale: The correct answer is C because the man whose wife has just been diagnosed with lung cancer is emotionally distressed, which can impact his ability to accurately interpret the message. This emotional state may lead to misinterpretations due to heightened stress and distraction. A: Well-adjusted adolescent - Unlikely to misinterpret as they are in a stable emotional state. B: Recovering alcoholic - Unlikely to misinterpret unless under the influence, which is not specified. D: Man with a hearing impairment - Unlikely to misinterpret with the presence of an interpreter for accurate communication.
Question 3 of 5
When performing a physical assessment, the first technique the nurse will always use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. When performing a physical assessment, inspection is always the first technique used as it provides an overall view of the patient's appearance and any obvious abnormalities. This includes observing skin color, posture, gait, facial expressions, and any visible signs of distress. Inspection helps the nurse gather initial information before proceeding to palpation, percussion, and auscultation. Palpation (A) involves using touch to assess areas such as texture, temperature, and tenderness. Percussion (C) is tapping on the body to produce sounds that indicate the location, size, and density of underlying structures. Auscultation (D) is listening to sounds produced by the body using a stethoscope. These techniques are important in a comprehensive physical assessment but come after inspection.
Question 4 of 5
The nurse is examining a preschool-aged child. What approach should the nurse use?
Correct Answer: B
Rationale: The correct answer is B because reassuring and providing feedback throughout the exam helps build trust and comfort with the child, making the exam less daunting. This approach fosters a positive therapeutic relationship and allows the child to feel supported and understood. Choice A may overwhelm the child with unnecessary information. Choice C may hinder the nurse's ability to conduct a thorough examination. Choice D is inappropriate and may cause distress to the child.
Question 5 of 5
When assessing an older adult, which vital sign changes occur with aging?
Correct Answer: B
Rationale: The correct answer is B: Widened pulse pressure. As people age, their blood vessels become less elastic, leading to an increase in systolic blood pressure and a decrease in diastolic blood pressure. This results in a widened pulse pressure. A: Increase in pulse rate is not a typical vital sign change with aging. C: Increase in body temperature is not a common vital sign change in older adults. D: Decrease in diastolic blood pressure is true but does not fully capture the overall vital sign changes that occur with aging.