ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
Correct Answer: A
Rationale: The correct answer is A. Note-taking may impede the nurse's observation of the patient's nonverbal behaviors because when the nurse is focused on writing notes, they may miss important nonverbal cues such as body language, facial expressions, and gestures. These nonverbal behaviors can provide valuable information about the patient's emotional state and overall well-being. By focusing on note-taking, the nurse may not fully engage in active listening or empathetic communication, which can hinder the therapeutic relationship. Choices B, C, and D are incorrect because note-taking does not necessarily allow the patient to continue at their own pace, shift attention away from the patient, or break eye contact to increase comfort level. In fact, effective communication involves active listening, maintaining eye contact, and being fully present with the patient. Note-taking should be done discreetly and minimally to avoid disrupting the interaction and compromising the quality of care.
Question 2 of 5
When performing a physical exam on an infant, the nurse should:
Correct Answer: C
Rationale: Rationale for choice C: Starting with less distressing areas such as the abdomen is recommended when performing a physical exam on an infant. This approach helps build rapport and trust with the infant, allowing them to feel more comfortable during the exam. It also helps prevent unnecessary stress and agitation, leading to a smoother and more successful examination process. By starting with non-invasive areas, the nurse can gradually progress to more sensitive areas without causing undue distress to the infant. Summary of why other choices are incorrect: A: Conducting the exam in a head-to-toe manner may overwhelm the infant and increase stress levels. B: Beginning with invasive procedures like ear examination can cause discomfort and lead to resistance from the infant. D: Waiting for the infant to wake up before starting the exam is not practical as the nurse should take advantage of the infant's calm state during sleep to perform the exam efficiently.
Question 3 of 5
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
Correct Answer: C
Rationale: Certainly! The correct answer is C: Diurnal cycle. Body temperature follows a circadian rhythm, peaking in the late afternoon and reaching its lowest point in the early morning. This cycle is influenced by the body's internal clock and is independent of external factors. A: Constipation does not directly influence body temperature. B: While emotions can affect body temperature temporarily, they are not a consistent factor influencing overall body temperature. D: Nocturnal cycle refers to nighttime activities and does not specifically impact body temperature regulation.
Question 4 of 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Correct Answer: A
Rationale: Step 1: The phase I Korotkoff sounds mark the systolic blood pressure (SBP). In this case, they begin at 200 mm Hg. Step 2: The phase V Korotkoff sounds mark the diastolic blood pressure (DBP). In this case, they disappear at 92 mm Hg. Step 3: Therefore, the blood pressure reading is recorded as SBP/DBP. So, the correct recording for this patient would be 200/92 mm Hg. Summary: Choice A is correct as it accurately reflects the SBP and DBP values observed during auscultation. Choices B, C, and D are incorrect because they either include additional or incorrect values for SBP and DBP.
Question 5 of 5
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
Correct Answer: C
Rationale: The correct answer is C because a newborn's skin is more permeable than that of an adult, making them more susceptible to fluid loss. This is due to the thinner and less developed skin barrier in newborns, which can lead to increased transepidermal water loss. A: Subcutaneous fat deposits being high in the newborn would actually help with insulation and temperature regulation, reducing the risk of fluid loss. B: Sebaceous glands being overproductive in the newborn would contribute to skin lubrication and protection, not fluid loss. D: The presence of vernix caseosa helps to protect the infant's skin and prevent excessive fluid loss, so an increase in vernix caseosa would not lead to fluid loss.