ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
Correct Answer: D
Rationale: The correct answer is D because it directly asks for the specific information needed without making assumptions or being overly suggestive. It is important to gather accurate and relevant information about past hospitalizations. Choice A is incorrect as it is presumptuous and can be seen as ageist. Choice B is incorrect as it assumes the patient's consent without explicitly asking. Choice C is incorrect as it assumes the patient mentioned past hospitalizations without confirming, and it is vague in requesting details. The best approach is to ask directly for the specific information needed, as in choice D.
Question 2 of 5
The nurse is assessing an older adult. Which action is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Minimize position changes during the exam. This is the most appropriate action because older adults may have mobility issues, so minimizing position changes helps prevent discomfort and potential injury. Speaking loudly (choice C) is not necessary unless the patient has hearing impairments. Completing the exam in one session (choice A) may be overwhelming and tiring for the patient. Performing a quick exam (choice D) may compromise the thoroughness of the assessment.
Question 3 of 5
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
Correct Answer: B
Rationale: The correct answer is B because leaving the thermometer in place for 3 to 4 minutes allows for an accurate reading of oral temperature. This duration ensures the mercury in the thermometer reaches equilibrium with the body temperature. Choice A is incorrect as waiting 30 minutes after ingesting hot or iced liquids is unnecessary for assessing oral temperature. Choice C is incorrect as placing the thermometer in front of the tongue and asking the patient to close their lips may not provide an accurate reading. Choice D is incorrect as shaking the thermometer down before taking the temperature is not necessary and can introduce errors in the reading.
Question 4 of 5
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
Correct Answer: A
Rationale: The correct answer is A because in infants, it is recommended to measure respirations first, followed by pulse and temperature. Infants have irregular breathing patterns, so measuring respirations first allows for the most accurate reading. Pulse and temperature can be affected by handling the infant, so they should be measured after respirations. Choice B is incorrect because vital signs in infants are typically measured at the same frequency as in adults, unless there are specific concerns or conditions. Choice C is incorrect because involving the parent in the procedure and encouraging the infant to handle the equipment may not be appropriate or necessary for measuring vital signs accurately. Choice D is incorrect because it is not necessary to perform a physical examination before measuring vital signs in an infant. It is important to follow the standard sequence of measuring respirations, then pulse, and temperature for accurate readings.
Question 5 of 5
A 22-year-old woman comes to the clinic because of severe sunburn and states, 'I was out in the sun for just a couple of minutes.' The nurse begins a medication review with her, paying special attention to which medication class?
Correct Answer: B
Rationale: The correct answer is B: Tetracyclines for acne. Tetracyclines are known to cause photosensitivity, increasing the risk of sunburn with minimal sun exposure. The nurse should review this medication class as the patient's severe sunburn may be a side effect. Nonsteroidal anti-inflammatory drugs (Choice A) are not directly related to photosensitivity. Proton pump inhibitors (Choice C) are used for reducing stomach acid, not linked to sunburn. Thyroid replacement hormone (Choice D) does not typically cause sunburn as a side effect. Therefore, the focus on tetracyclines is crucial in this scenario.