ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to 'warm up' and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Correct Answer: B
Rationale: The correct answer is B. Stopping down to the toddler's level and asking her about the toy she is holding is the best approach because it shows respect for the toddler's interests and allows for engagement on her terms, fostering a sense of trust and comfort. This approach acknowledges the toddler's autonomy and helps build a positive relationship. Option A is incorrect because tickling the toddler may not be appropriate and could potentially lead to discomfort or fear. Option C is incorrect as continuing to ignore the toddler may cause her to feel neglected and hinder the establishment of rapport. Option D is incorrect because it is important for the mother to be present to provide comfort and support during the examination.
Question 2 of 5
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
Correct Answer: A
Rationale: The correct answer is A because a tympanic membrane thermometer provides rapid measurements, making it ideal for uncooperative younger children. This is crucial in clinical settings where quick and accurate temperature readings are necessary. Choice B is incorrect as the TMT may not be the most accurate method for newborn infants due to their delicate ear structure. Choice C is incorrect as TMT devices can be relatively expensive. Choice D is incorrect as studies may not strongly support the use of TMT in children under 6 years due to factors like accuracy and reliability.
Question 3 of 5
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
Correct Answer: B
Rationale: The correct answer is B: Detect the presence of an auscultatory gap. Performing a palpated pressure before auscultating blood pressure helps detect an auscultatory gap, which is a period of silence between the systolic and diastolic readings. This is important because relying solely on Korotkoff sounds may lead to missing this gap, resulting in inaccurate blood pressure readings. The other choices are incorrect because: A: More clearly hearing Korotkoff sounds is not the primary purpose of palpated pressure. C: Palpated pressure does not specifically help avoid missing a falsely elevated blood pressure. D: Identifying phase IV of Korotkoff sounds is not the main objective of performing palpated pressure.
Question 4 of 5
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
Correct Answer: D
Rationale: The correct answer is D: Replaced every 4 weeks. The epidermis is continuously renewing itself through a process called desquamation, where old cells are shed and replaced by new ones. This turnover process typically takes around 4 weeks. This statement would be included in the module to educate the nursing staff on the dynamic nature of the epidermis. A: Highly vascular is incorrect because the epidermis is avascular, meaning it does not contain blood vessels. B: Thick and tough is incorrect as the epidermis is actually thin and serves as a protective barrier for the body. C: Thin and nonstratified is incorrect because the epidermis is stratified, consisting of multiple layers of cells.
Question 5 of 5
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. In patients with chronic respiratory conditions like emphysema and bronchitis, clubbing of the nails can be seen due to chronic hypoxia. This is characterized by a bulbous enlargement of the fingertips and nails curving over the fingertips. This finding is related to chronic oxygen deprivation, indicating long-standing respiratory issues. Incorrect choices: A: Anasarca - Generalized edema, not typically associated with emphysema and bronchitis. B: Scleroderma - Connective tissue disorder causing skin thickening, not directly related to respiratory conditions. C: Pedal erythema - Redness of the feet, not a common finding in emphysema and bronchitis.