ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
During a cardiovascular assessment, the nurse auscultates a murmur that occurs during diastole. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Mitral stenosis. During diastole, the mitral valve should be closed, allowing blood to flow from the left atrium to the left ventricle. A murmur during diastole indicates turbulent blood flow across a stenotic mitral valve. Mitral stenosis causes decreased flow from the left atrium to the left ventricle during diastole, leading to increased pressure in the left atrium and the pulmonary circulation. Aortic regurgitation (A) would present with a murmur during diastole, but it is typically heard in early diastole. Tricuspid regurgitation (C) would present with a murmur during systole. Systolic heart failure (D) is not associated with a diastolic murmur.
Question 2 of 5
A rise of 1-degree Fahrenheit of temperature will increase the pulse rate by how many beats per minute?
Correct Answer: C
Rationale: A well-established physiological principle states that for every 1°F increase in body temperature, the pulse rate typically rises by about 5 beats per minute, making Choice C correct. This occurs because fever increases metabolic demand, prompting the heart to pump faster to deliver oxygen and nutrients. 3, and 4, underestimate this effect, while 6, slightly overestimates it based on standard clinical observations. For example, a person with a normal pulse of 70 bpm at 98.6°F might see it rise to 75 bpm at 99.6°F. This relationship is part of the bodys compensatory response to heat stress or infection, mediated by the autonomic nervous system. While individual variations exist due to age or fitness, 5 bpm is the widely accepted average in nursing and medical literature, making C the most accurate choice here.
Question 3 of 5
Which groups body temperature changes more rapidly in response to both heat and cold air temperatures?
Correct Answer: A
Rationale: Infants and children, is correct because their higher surface-area-to-mass ratio and immature thermoregulation cause rapid temperature shifts. Infants lack shivering efficiency and sweat less, while childrens thin skin and high metabolism amplify responses to heat/cold. Older adults, adapt slowly due to reduced metabolism and circulation. Women, and Men, vary less by sex than age. Pediatric nursing notes infants can drop to hypothermia or spike to hyperthermia fastere.g., a cold room lowers temperature in minutes. This vulnerability requires close monitoring, making A the precise answer per developmental physiology.
Question 4 of 5
Which of the following patients would be an appropriate candidate for the use of a radiant heater?
Correct Answer: B
Rationale: Radiant heaters provide controlled warmth, ideal for specific patients. An older adult with hypothermia needs warming but typically via blankets or warm fluids, not radiant heaters. A premature infant requires thermoregulation due to immature systems, making radiant heaters standard in neonatal care. An infant with jaundice uses phototherapy, not heat. A near-drowning child needs rewarming but not specifically via radiant heaters. Choice B is correct as premature infants' inability to maintain body temperature aligns with radiant heater use, a common NICU intervention supported by pediatric nursing protocols.
Question 5 of 5
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral is unreliable with agitation. Rectal risks injury or vagal stimulation. Axillary is slow and less accurate. Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.