ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. This is because the patient's emotional response (laughing loudly) does not match the content of the picture (decapitated head), which is considered inappropriate. Confusion (A) refers to a lack of understanding, ambivalence (B) is conflicting feelings, and depersonalization (C) is feeling disconnected from oneself, none of which fully explain the patient's behavior. Inappropriate affect best describes the mismatch between the patient's emotional expression and the situation presented.
Question 2 of 5
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Be mindful of the child's modesty. This is the most appropriate action because it respects the child's privacy and helps build trust. Starting with the genitalia (B) can be invasive and inappropriate. Talking about equipment (A) may not address the child's emotional needs. Performing a head-to-toe assessment starting with the chest (D) may overlook the importance of considering the child's comfort and modesty. Being mindful of modesty shows respect for the child's dignity and autonomy.
Question 3 of 5
The nurse should measure rectal temperatures in which of these patients?
Correct Answer: C
Rationale: The correct answer is C because rectal temperatures are most accurate in patients who are unable to hold a thermometer in their mouth, such as comatose adults. Rectal temperatures closely reflect core body temperature. Choice A (school-age child) may be able to hold a thermometer in their mouth. Choice B (older adult) may have conditions affecting rectal tissue. Choice D (patient receiving oxygen by nasal cannula) may have altered oxygen levels affecting temperature readings.
Question 4 of 5
The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:
Correct Answer: B
Rationale: The correct answer is B: Yield a falsely high blood pressure. Using a standard-sized cuff on an obese patient will lead to inaccurate readings because the cuff will not fit properly around the arm. This can result in increased pressure on the brachial artery, leading to a falsely high blood pressure reading. The other choices are incorrect because: A: Using a standard cuff on an obese patient will result in a falsely high, not low, blood pressure reading. C: The cuff size plays a significant role in blood pressure accuracy, so the reading will not be the same with a standard-sized cuff. D: While technique can impact blood pressure readings, in this scenario, the inaccurate reading is primarily due to the incorrect cuff size, not the technique of the person performing the assessment.
Question 5 of 5
When checking for proper blood pressure cuff size, which guideline is correct?
Correct Answer: D
Rationale: The correct answer is D because the width of the rubber bladder should ideally be around 40% of the arm circumference for proper blood pressure measurement. This is crucial for accurate readings as using a cuff that is too narrow or too wide can lead to incorrect readings. Option A is incorrect as one size does not fit all. Option B is incorrect as the length of the bladder is not the key factor. Option C is incorrect as the width of the bladder should be around 40%, not 80%, of the arm circumference.