ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Correct Answer: B
Rationale: The correct answer is B. In this scenario, the nurse should prioritize immediate actions to ensure the patient's survival. By simultaneously asking history questions, performing the examination, and initiating life-saving measures, the nurse can quickly gather essential information while addressing the patient's critical needs. This approach allows for efficient data collection without compromising the patient's well-being. Choices A, C, and D are incorrect because they do not prioritize the patient's immediate needs. A delays life-saving measures by collecting history first, which can be detrimental in a critical situation. C focuses on detailed history information that is not essential for immediate care. D delays gathering any history information, which is crucial for understanding the patient's condition and providing appropriate care.
Question 2 of 5
An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?
Correct Answer: C
Rationale: The correct answer is C: Ischemia. The elderly woman's history of coronary bypass surgery suggests a higher risk for vascular issues like mesenteric ischemia. The severe, diffuse abdominal pain that is not exacerbated by palpation is a classic presentation of mesenteric ischemia. This condition results from inadequate blood supply to the intestines and can lead to severe abdominal pain. Malingering (A) is unlikely as there is a legitimate medical history. Neuropathy (B) typically presents with different symptoms such as numbness or tingling rather than severe abdominal pain. Physical abuse (D) does not align with the clinical presentation and medical history.
Question 3 of 5
When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 92/42 mm Hg indicates hypotension, which can be a sign of septic shock in a patient with bacterial meningitis. This finding requires immediate attention as it can lead to serious complications and requires prompt intervention to stabilize the patient's hemodynamic status. A: A positive Kernig's sign and complaints of a stiff neck are common findings in patients with bacterial meningitis but do not require immediate reporting as they are expected symptoms. C: A temperature of 101°F is slightly elevated but not a critical finding that necessitates immediate reporting compared to hypotension.
Question 4 of 5
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Head turned to the side. This position can potentially increase intracranial pressure by obstructing venous drainage and impeding blood flow. The rationale is to maintain cerebral perfusion and reduce the risk of complications. A: Head midline is correct as it promotes proper alignment and reduces strain on the neck muscles. C: Neck in neutral position is correct to prevent additional pressure on the neck and optimize blood flow. D: Head of bed elevated 30 to 45 degrees is correct to facilitate venous drainage and reduce intracranial pressure.
Question 5 of 5
The nurse is teaching a patient about hypertension management. Which statement by the patient indicates a need for further teaching?
Correct Answer: B
Rationale: Correct Answer: B Rationale: Choice B indicates a misunderstanding as stopping medications once blood pressure is normal can lead to uncontrolled hypertension. Patients with hypertension typically require long-term medication management to maintain blood pressure within a healthy range. This choice reflects a need for further teaching to emphasize the importance of medication adherence. Summary: A: Checking blood pressure regularly is a good practice for hypertension management. C: Reducing salt and processed food intake helps in managing hypertension. D: Incorporating exercise into daily routine is beneficial for hypertension management.