ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?
Correct Answer: C
Rationale: The correct answer is C because smoking, hypertension, obesity, diabetes, and high cholesterol are all major risk factors for heart disease supported by research. Smoking damages blood vessels, hypertension increases heart strain, obesity leads to various heart issues, diabetes affects blood sugar levels, and high cholesterol can lead to plaque buildup in arteries. Choice A is incorrect because stress is not a major risk factor for heart disease compared to the other factors listed. Choice B is incorrect as personality type is not a significant risk factor for heart disease. Choice D is incorrect because alcohol consumption is not as strongly associated with heart disease as the other factors listed in choice C.
Question 2 of 5
A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _____ the left leg.
Correct Answer: C
Rationale: The correct answer is C: Ischemia caused by a partial blockage of an artery supplying the left leg. In this scenario, the patient experiences pain in the left calf during exercise, which is relieved by resting, suggesting intermittent claudication. This is typically caused by partial blockage of an artery, leading to reduced blood flow and oxygen supply to the muscles during exercise. Venous obstruction (A) and claudication due to venous abnormalities (B) are related to issues in the venous system, not arterial supply. Ischemia due to complete arterial blockage (D) would result in more severe and constant pain, not relieved by resting.
Question 3 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 4 of 5
You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning?
Correct Answer: B
Rationale: The correct answer is B because reassuring the patient that urinary symptoms are benign and not related to cancer is not a component of adaptive questioning. Adaptive questioning involves adjusting the questioning technique based on the patient's responses to gather more information effectively. Reassurance may prematurely close the conversation or influence the patient's responses. Directed questioning (A) is a component of adaptive questioning as it helps gather information systematically. Offering multiple choices (C) helps clarify the patient's symptoms. Asking the patient to explain further (D) is also a component of adaptive questioning as it seeks detailed information to better understand the patient's experience.
Question 5 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.