ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:
Correct Answer: A
Rationale: The correct answer is A: Plan to defer the rest of the mental status examination. Given the patient's dysarthric speech and lethargy, it is essential to prioritize the patient's physical well-being and safety over completing the mental status examination. Dysarthric speech may indicate a potential neurological issue that needs immediate attention. Deferring the examination allows for a more thorough assessment once the patient's physical condition stabilizes. Choice B is incorrect because skipping the language portion and proceeding to mood and affect assessment neglects the importance of addressing the potential underlying medical issue causing the dysarthric speech. Choice C is incorrect because conducting an in-depth speech evaluation and deferring the mental status examination may delay necessary medical intervention for the patient's condition. Choice D is incorrect because assuming dysarthria is always associated with severe depression and jumping to assess for suicidal thoughts without addressing the immediate physical concerns is premature and may lead to overlooking critical medical issues.
Question 2 of 5
The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature?
Correct Answer: B
Rationale: Step 1: The correct answer is B: Dorsal surface of the hand; the skin is thinner on this surface than on the palms. Step 2: The dorsal surface of the hand has thinner skin, allowing for better sensitivity to temperature changes. Step 3: Thinner skin on the dorsal surface allows for more accurate assessment of subtle temperature variations. Step 4: Fingertips (choice A) are more sensitive to texture, not temperature. Ulnar portion (choice C) does not have enhanced temperature sensitivity. Palmar surface (choice D) is not the most sensitive to temperature variations. Summary: Choice B is correct because the dorsal surface of the hand offers better temperature sensitivity due to its thinner skin compared to other parts of the hand. Choices A, C, and D are incorrect as they do not provide the optimal location for assessing skin temperature.
Question 3 of 5
When performing a physical exam on an infant, the nurse should:
Correct Answer: C
Rationale: Rationale for choice C: Starting with less distressing areas such as the abdomen is recommended when performing a physical exam on an infant. This approach helps build rapport and trust with the infant, allowing them to feel more comfortable during the exam. It also helps prevent unnecessary stress and agitation, leading to a smoother and more successful examination process. By starting with non-invasive areas, the nurse can gradually progress to more sensitive areas without causing undue distress to the infant. Summary of why other choices are incorrect: A: Conducting the exam in a head-to-toe manner may overwhelm the infant and increase stress levels. B: Beginning with invasive procedures like ear examination can cause discomfort and lead to resistance from the infant. D: Waiting for the infant to wake up before starting the exam is not practical as the nurse should take advantage of the infant's calm state during sleep to perform the exam efficiently.
Question 4 of 5
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
Correct Answer: C
Rationale: Certainly! The correct answer is C: Diurnal cycle. Body temperature follows a circadian rhythm, peaking in the late afternoon and reaching its lowest point in the early morning. This cycle is influenced by the body's internal clock and is independent of external factors. A: Constipation does not directly influence body temperature. B: While emotions can affect body temperature temporarily, they are not a consistent factor influencing overall body temperature. D: Nocturnal cycle refers to nighttime activities and does not specifically impact body temperature regulation.
Question 5 of 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Correct Answer: A
Rationale: Step 1: The phase I Korotkoff sounds mark the systolic blood pressure (SBP). In this case, they begin at 200 mm Hg. Step 2: The phase V Korotkoff sounds mark the diastolic blood pressure (DBP). In this case, they disappear at 92 mm Hg. Step 3: Therefore, the blood pressure reading is recorded as SBP/DBP. So, the correct recording for this patient would be 200/92 mm Hg. Summary: Choice A is correct as it accurately reflects the SBP and DBP values observed during auscultation. Choices B, C, and D are incorrect because they either include additional or incorrect values for SBP and DBP.