ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely?
Correct Answer: D
Rationale: The correct answer is D: CN X lesion on the right. When the uvula deviates to the left upon touching the soft palate, it indicates a lesion of the right vagus nerve (CN X). The uvula is innervated by the vagus nerve, and when there is a lesion on the right side, the uvula will deviate away from the affected side due to the unopposed action of the intact left vagus nerve. Choices A and B are incorrect because cranial nerve IX (glossopharyngeal nerve) does not innervate the uvula. Choice C is incorrect as a lesion of the left vagus nerve would cause the uvula to deviate to the right, not the left.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse is performing an abdominal assessment and notes a bruit over the aorta. What does this finding indicate?
Correct Answer: B
Rationale: Step 1: A bruit is an abnormal sound caused by turbulent blood flow. Step 2: The presence of a bruit over the aorta indicates turbulent blood flow, possibly due to atherosclerosis or an aneurysm. Step 3: This finding is significant and requires further assessment and monitoring. Step 4: Therefore, choice B is correct as it accurately reflects the indication of a bruit over the aorta. Summary: Choices A, C, and D are incorrect because a bruit is not a normal vascular sound, does not indicate absence of bowel sounds, and is not related to increased peristalsis.