ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse reflects cardiac response but isn't directly hypothalamic. Respirations may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
Question 2 of 5
The respiratory rate is...
Correct Answer: C
Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.
Question 3 of 5
The following patients require routine vital signs to be obtained by the nursing assistive personnel (NAP). You instruct the NAP to obtain vital signs on which patient first?
Correct Answer: B
Rationale: Priority is the 65-year-old post-treadmill test, out of breath , indicating potential distress needing immediate assessment. The man eating needs delay for BP accuracy but isn't urgent. The teen watching TV is stable. The mother post-argument may have elevated BP but lacks acute signs. Choice B is correct, per triage principles prioritizing respiratory or exertion-related symptoms in older adults, who are at higher risk for cardiac or pulmonary issues.
Question 4 of 5
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient's blood pressure?
Correct Answer: D
Rationale: Caffeine and smoking elevate BP temporarily; assessing post-exposure skews results. Both affect BP (A incorrect). Three-hour delay is impractical. Exercise raises BP. Choice D is correct, per nursing timing considerations.
Question 5 of 5
A nurse is assessing a client's pulse rate. Which location should the nurse use to accurately measure the pulse rate?
Correct Answer: B
Rationale: The carotid artery is easily palpable and close to the surface, offering accurate pulse rate measurement, especially in emergencies. Radial is common but less central. Femoral and popliteal are deeper, used in specific cases. Choice B is correct, per the explanation, aligning with nursing preference for carotid in critical or routine checks due to its reliability and accessibility.