ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?
Correct Answer: A
Rationale: The correct answer is A: Hepatitis A. Jaundice without risk factors for other types of hepatitis indicates an acute infection, which is most commonly caused by Hepatitis A virus. This virus is usually transmitted through contaminated food or water, making it more likely for a daycare worker to contract due to close contact with children. Hepatitis B is typically transmitted through blood or sexual contact, which the worker denies. Hepatitis C is also transmitted through blood, which is not reported. Hepatitis D requires Hepatitis B infection for replication, and since Hepatitis B is not indicated in this case, Hepatitis D is unlikely.
Question 2 of 5
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Correct Answer: D
Rationale: The correct answer is D. Calling the physician immediately is crucial because a severe headache in a client with a cerebral aneurysm may indicate a rupture, a life-threatening emergency. The physician needs to be notified promptly for urgent intervention. Reassessing the client in 15 minutes (Choice A) may delay necessary action. Administering an analgesic (Choice B) without knowing the underlying cause of the headache could mask symptoms and delay appropriate treatment. Informing the nurse manager (Choice C) is not the priority; direct communication with the physician for immediate medical intervention is essential in this situation.
Question 3 of 5
The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?
Correct Answer: B
Rationale: The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement. A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results. C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size. D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.
Question 4 of 5
In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.
Question 5 of 5
A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?
Correct Answer: B
Rationale: The correct answer is B: Re-examine the patient and establish new goals. This is the most appropriate next step because if the patient has not shown progress in over three weeks, it indicates a need to reassess the current treatment plan and goals. By re-examining the patient, the therapist can identify any factors hindering progress and adjust the treatment plan accordingly. This proactive approach ensures the patient receives the most effective care. Choice A: Transferring the patient to another therapist does not address the root cause of the lack of progress and may disrupt continuity of care. Choice C: Simply continuing to modify the treatment plan without re-evaluating the patient may not lead to improved outcomes. Choice D: Alerting the referring physician should be done after reassessment and establishing new goals, as the physician may require updated information but is not the immediate next step.