ATI RN
RN Vital Signs Assessment ATI Questions
Question 1 of 4
A nurse is assessing a client's body temperature and notices shivering and goosebumps. What action should the nurse take?
Correct Answer: A
Rationale: Shivering and goosebumps indicate the body is raising its temperature, likely due to cold. Warm blankets prevent heat loss and enhance comfort. Antipyretics treat fever, not applicable here. Cool compresses worsen heat loss. Notifying the provider is unnecessary for a normal response. Choice A is correct, per the explanation, reflecting nursing's role in supporting thermoregulation during hypothermia or chills.
Question 2 of 4
The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?
Correct Answer: C
Rationale: Rapid and deep respirations compensate for high CO2 and low O2 in shock, per the answer key, as the body attempts to correct acid-base imbalance (Kussmaul breathing). Absent or slow contradict this. Noisy isn't specific. Nurses recognize this pattern to address respiratory distress urgently.
Question 3 of 4
A patient in a physicians office has a single blood pressure (BP) reading of 150/92. Should the patient be taught about hypertension?
Correct Answer: C
Rationale: A single BP of 150/92 isn't enough for hypertension teaching, per the answer key, needing multiple readings (e.g., JNC 8). Time or gender don't determine this. High enough overlooks confirmation. Nurses educate based on trends.
Question 4 of 4
A nurse performing physical assessments of residents in a long-term care facility describes to the student nurse common head and neck variations in the older adult. Which of the following accurately defines these variations? Select all that apply.
Correct Answer: A
Rationale: Decreased vision , entropion/ectropion , and hearing loss are common in older adults, per the answer key (A, D, E). Arcus senilis is true but not selected here. Adaptation decreases. Nurses, per Taylor, note these aging changes.