ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
A pregnant woman states, 'I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor.' The nurse responds by stating, 'Oh, don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.' Which statement is true regarding this response? The nurse's reply was a:
Correct Answer: B
Rationale: By providing false assurance or reassurance, this courage builder relieves the woman's anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.
Question 2 of 5
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
Correct Answer: B
Rationale: The correct answer is B) Prehypertension. Prehypertension is defined as a blood pressure reading that is higher than normal but not high enough to be considered hypertension. In this case, the patient's average blood pressure reading of 126/86 mm Hg falls within the prehypertension range. Option A) Normal blood pressure is incorrect because the patient's average blood pressure reading is higher than what is considered normal (which is typically around 120/80 mm Hg). Option C) Stage 1 hypertension and Option D) Stage 2 hypertension are also incorrect because the patient's blood pressure readings do not fall within the ranges defined for these categories. Stage 1 hypertension is typically defined as readings between 130-139/80-89 mm Hg, and Stage 2 hypertension is readings above 140/90 mm Hg. Educationally, understanding blood pressure categories is crucial for healthcare professionals to accurately assess and manage patients' cardiovascular health. Monitoring blood pressure trends over time helps in identifying potential health risks and guiding appropriate interventions to prevent complications associated with hypertension. It is essential for nurses to interpret and classify blood pressure readings correctly to provide optimal patient care.
Question 3 of 5
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?
Correct Answer: A
Rationale: The correct answer is A) Respirations should be counted for 1 full minute, noticing rate and rhythm. This is the appropriate way to assess a child's respirations, especially when irregularities are suspected. Counting respirations for a full minute provides a more accurate representation of the child's breathing pattern, allowing the nurse to observe any variations in rate, depth, and rhythm. Option B) Child's pulse and respirations should be simultaneously checked for 30 seconds, is incorrect because focusing on both pulse and respirations simultaneously may lead to inaccuracies in counting one or both of these vital signs. It is important to assess respirations independently for a full minute to ensure accuracy. Option C) Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern, is incorrect as it is not practical or necessary to monitor a child's respirations for such an extended period of time during a routine assessment. One minute is generally sufficient to assess respiratory rate and rhythm. Option D) Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute, is incorrect because this method may not capture any irregularities or fluctuations in the child's respiratory pattern that could be observed over a full minute. In an educational context, understanding the proper technique for assessing vital signs in pediatric patients is crucial for providing safe and effective nursing care. Teaching students to count respirations for a full minute allows them to develop the skills necessary to accurately assess and monitor a child's breathing pattern, which is essential in detecting any potential respiratory issues or abnormalities. It also emphasizes the importance of thorough assessment techniques in pediatric nursing practice to ensure the well-being of young patients.
Question 4 of 5
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
Correct Answer: A
Rationale: In this scenario, option A is the correct answer because the patient's dizziness could be indicative of orthostatic hypotension, a common side effect of antihypertensive medications in the elderly. By evaluating the patient's blood pressure and pulse in the supine, sitting, and standing positions, the nurse can assess for postural changes that may be causing the dizziness. This is crucial for the early detection and management of orthostatic hypotension to prevent falls and other complications in older adults. Option B is incorrect because asking the patient to walk around the room before assessing blood pressure could potentially exacerbate the dizziness and is not a standard practice for evaluating orthostatic hypotension. Option C is incorrect because assessing blood pressure only at the beginning and end of the examination may miss important changes that occur with position changes, which are key in diagnosing orthostatic hypotension. Option D is incorrect because waiting 5 minutes between blood pressure measurements on different arms does not address the specific issue of orthostatic hypotension related to changes in position. Educationally, understanding the importance of assessing vital signs in different positions is essential for nurses to provide comprehensive care, especially for older adults who may be more prone to orthostatic hypotension. This rationale highlights the significance of thorough assessment techniques in addressing potential medication side effects and ensuring patient safety and well-being.
Question 5 of 5
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Color variation. The nurse is concerned with this finding because a mole that has started to burn and bleed, in addition to displaying color variation, could be indicative of malignant melanoma, a type of skin cancer. Color variation in pigmented lesions, such as moles, can be a warning sign of possible skin cancer as it may indicate uneven distribution of melanin or the presence of multiple colors within the lesion. The other options are incorrect in this context because: - B) Border regularity: While irregular borders can also be a sign of skin cancer, in this case, the presentation of burning and bleeding in addition to color variation raises more concern. - C) Symmetry of lesions: Symmetry of lesions is one of the ABCDEs of melanoma assessment, but in this case, the symptoms presented by the patient are more concerning than just symmetry. - D) Diameter of less than 6 mm: While the size of a lesion is important in assessing potential malignancy, the symptoms of burning and bleeding in this case take precedence over the size of the lesion. Educationally, this question highlights the importance of recognizing danger signs of pigmented lesions and the significance of color variation as a key indicator of potential skin cancer. Nurses and healthcare providers must be vigilant in assessing changes in moles and lesions and understand the significance of various characteristics in determining the need for further evaluation and management.