ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Barriers to incorporating EBP include:
Correct Answer: A
Rationale: Step 1: Evidence-based practice (EBP) requires nurses to critically evaluate research studies. Step 2: To incorporate EBP, nurses need research skills to assess the quality of studies. Step 3: Lack of research skills hinders nurses from effectively utilizing EBP. Step 4: Choice A is correct as it directly addresses a barrier to incorporating EBP. Summary: Choices B, C, and D are incorrect as they do not specifically relate to the need for research skills in evaluating the quality of research studies, which is essential for implementing EBP.
Question 2 of 5
A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
Correct Answer: B
Rationale: The correct answer is B: Consensual reaction. This phenomenon occurs when shining light into one eye causes both pupils to constrict due to the pupillary light reflex. The optic nerves from both eyes converge in the brain, leading to the consensual reaction in the non-illuminated eye. Direct reaction (A) refers to the pupil directly exposed to light. Near reaction (C) is associated with changes in pupil size in response to focusing on near objects. Accommodation (D) is the process of adjusting the lens shape for near vision and is not directly related to pupillary constriction.
Question 3 of 5
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
Correct Answer: A
Rationale: The correct answer is A: It is a splenic rub. The rough grating noise heard on examination is characteristic of a splenic rub, which occurs when the peritoneum overlying the spleen rubs against the spleen itself. This is often associated with conditions like splenic infarction or abscess. In Cody's case, with his history of leukemia and an enlarged spleen, this finding is concerning and warrants further investigation. Summary of other choices: B: It is not a variant of bowel noise as bowel noises are typically more high-pitched and gurgling in nature. C: It is not borborygmi, which refers to the normal sounds produced by the movement of gas and fluid in the intestines. D: It is not a vascular noise as those are usually associated with blood flow abnormalities and are not typically heard in the left upper quadrant.
Question 4 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D because in children, the sound produced by percussing over the lungs can sometimes be louder, longer, and lower in pitch compared to adults due to their thinner chest walls. This finding is considered normal for a child of this age and should not raise concerns. Palpating for pain or tenderness (Choice A) is not necessary as the loud tones are not indicative of pathology. Asking the child to take shallow breaths (Choice B) would not change the percussion findings. Referring the child immediately (Choice C) is unwarranted as the findings are within the expected range for a 4-year-old.
Question 5 of 5
The nurse recognizes that the bell of the stethoscope is used to detect which type of sounds?
Correct Answer: B
Rationale: The correct answer is B because low-pitched sounds like heart murmurs are best detected using the bell of the stethoscope. The bell is designed to pick up low-frequency sounds with more clarity and resonance due to its shape and size. Heart murmurs typically fall into the category of low-pitched sounds, making the bell ideal for their detection. Choice A is incorrect because high-pitched sounds like breath sounds are better detected using the diaphragm of the stethoscope, not the bell. Choice C is incorrect as sounds over a large surface area would be better detected using the diaphragm as well. Choice D is incorrect because the amplitude of the sound does not determine whether the bell or diaphragm is used; it is more about the frequency or pitch of the sound.