ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
In using verbal responses to assist the patient's narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective. An example of a verbal response that focuses on the health care provider's perspective would be:
Correct Answer: D
Rationale: The correct answer is D: Confrontation. Confrontation is a verbal response that focuses on the health care provider's perspective by directly addressing discrepancies or inconsistencies in the patient's narrative. This technique helps challenge the patient's denial or resistance to change, promoting self-awareness and insight. In contrast, empathy (choice A) involves understanding and sharing the patient's feelings, reflection (choice B) involves restating or paraphrasing the patient's words, and facilitation (choice C) involves encouraging the patient to continue expressing their thoughts. These responses all focus on the patient's frame of reference, rather than challenging or addressing the provider's perspective.
Question 2 of 5
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Correct Answer: B
Rationale: The correct answer is B because giving feedback and reassurance during the examination is appropriate for a 4-year-old child. This approach helps to build trust, reduce anxiety, and make the child feel more comfortable. Providing reassurance also helps the child understand what is happening and promotes cooperation during the examination. Explanation for other choices: A: Explaining procedures in detail may overwhelm and increase anxiety in a 4-year-old child. C: Avoiding asking the child to remove clothing may hinder a thorough examination and compromise the child's health. D: Performing a head-to-toe examination starting with the ears may not be developmentally appropriate or engaging for a 4-year-old child.
Question 3 of 5
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
Correct Answer: C
Rationale: The correct answer is C. The tympanic method reduces the risk of cross-contamination compared to rectal temperature measurement. This is because the tympanic thermometer does not come into direct contact with mucous membranes or bodily fluids, unlike rectal thermometers. Cross-contamination can occur when pathogens are transmitted between individuals or surfaces. Therefore, using the tympanic method decreases the chances of spreading infections. Choice A is incorrect as tympanic temperature measurement is quicker compared to rectal temperature measurement. Choice B is incorrect as the tympanic method is non-invasive and generally well-tolerated. Choice D is incorrect as the tympanic membrane reflects the temperature of the blood vessels in the temporal artery, not the ophthalmic artery.
Question 4 of 5
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
Correct Answer: B
Rationale: The correct answer is B because auscultating an apical rate for 1 minute allows for a more accurate assessment of the infant's heart rate, which can vary. This method helps detect any abnormalities, such as sinus arrhythmia commonly seen in infants. Auscultating the apical rate is more accurate than palpating the radial pulse in infants due to their small size and delicate nature. Assessing blood pressure in infants requires specialized equipment, not just a stethoscope with a large diaphragm piece. Observing the chest for respiratory rate is important but does not provide a full assessment of vital signs.
Question 5 of 5
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
Correct Answer: D
Rationale: The correct answer is D: Importance of sunscreen and avoiding direct sunlight. Rationale: 1. Oral hypoglycemic agents can increase sensitivity to sunlight, leading to sunburn or skin damage. 2. Diabetic patients are at higher risk of skin complications, so protecting the skin from sunlight is crucial. 3. Sun exposure can also affect blood sugar levels, potentially causing fluctuations in glucose levels. 4. Use of sunscreen and avoiding direct sunlight can help prevent skin issues and maintain overall health for a diabetic patient. Summary: A: Increased possibility of bruising - Not directly related to diabetes or oral hypoglycemic agents. B: Skin sensitivity as a result of exposure to salt water - Not a common concern for diabetic patients on oral hypoglycemic agents. C: Lack of availability of glucose-monitoring supplies - Important but not directly related to the side effects of oral hypoglycemic agents.