ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
Correct Answer: A
Rationale: The correct answer is A: 1+/0-4+. This grading scale indicates mild pitting edema. The "1+" signifies slight indentation that disappears rapidly (mild), and "0-4+" indicates the depth of the indentation, with 1+ being the lowest on the scale. This specific documentation helps accurately communicate the severity of the edema. Summary of other choices: - B: 3+/0-4+: This indicates moderate to severe pitting edema, not appropriate for mild edema. - C: 4+/0-4+: This indicates severe pitting edema, not reflective of mild edema. - D: Brawny edema: Brawny edema is non-pitting and does not apply to the scenario described.
Question 2 of 5
A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this is at her hands and feet. She does not remember the child's lips turning blue. She is otherwise eating and growing well. What would you do now?
Correct Answer: A
Rationale: Step 1: "Turns blue" at hands and feet without lips involvement suggests acrocyanosis, a common benign condition in newborns. Step 2: Acrocyanosis is a result of immature circulation and is typically self-limiting. Step 3: The child is otherwise well-nourished and growing, indicating no acute distress. Step 4: Reassuring the mother about acrocyanosis being normal helps alleviate her concerns. Summary: B: Echocardiogram is unnecessary as the symptoms do not suggest structural heart disease. C: Hospitalization is excessive for a benign condition like acrocyanosis. D: Casting doubt on the mother's story is not appropriate without evidence otherwise.
Question 3 of 5
M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse?
Correct Answer: A
Rationale: The correct answer is A: "Tell me what prompted that question." This response shows empathy, encourages open communication, and allows M.J. to express her concerns. By asking for clarification, the nurse can assess M.J.'s understanding and emotional state, providing an opportunity to address her fears and offer support. This approach respects M.J.'s autonomy and allows her to share her feelings. Choice B: "I will ask your physician to discuss this matter with you." This response avoids addressing M.J.'s concerns directly and may not respect her preferences for communication. Choice C: "Let's take each day as it comes." This response does not directly address M.J.'s question and may come across as dismissive of her concerns. Choice D: "I think you should discuss that with your family." This response does not acknowledge M.J.'s feelings or provide direct support, potentially undermining the therapeutic relationship between the nurse and M.J.
Question 4 of 5
Sensory information to the area of skin over index finger (dermatome) is subserved by afferent fibers from which dorsal root?
Correct Answer: C
Rationale: The correct answer is C7 because the index finger is innervated by the C7 dermatome. Each spinal nerve innervates a specific area of skin called a dermatome. In this case, the C7 spinal nerve is responsible for providing sensory information to the skin over the index finger. Choices A (C5), B (C6), and D (C8) are incorrect as they do not correspond to the dermatome responsible for innervating the index finger. Therefore, the correct answer is C7 based on the specific dermatomal distribution of sensory fibers.
Question 5 of 5
An anterior superior iliac spine (ASIS) avulsion fracture can be caused by forceful contraction of which muscle?
Correct Answer: C
Rationale: The correct answer is C, the Sartorius muscle. An ASIS avulsion fracture occurs due to a sudden and forceful contraction of the Sartorius muscle, which attaches to the ASIS. This muscle acts to flex, abduct, and laterally rotate the hip, and its abrupt contraction can lead to avulsion of the ASIS. The other choices, such as A (Long head of the biceps femoris), B (Vastus intermedius muscle), and D (Iliopsoas muscle), do not directly attach to the ASIS and are not involved in causing this specific type of fracture.