ATI RN
Assess Vital Signs Questions
Question 1 of 5
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
Correct Answer: C
Rationale: The correct answer is C because the man whose wife has just been diagnosed with lung cancer is emotionally distressed, which can impact his ability to accurately interpret the message. This emotional state may lead to misinterpretations due to heightened stress and distraction. A: Well-adjusted adolescent - Unlikely to misinterpret as they are in a stable emotional state. B: Recovering alcoholic - Unlikely to misinterpret unless under the influence, which is not specified. D: Man with a hearing impairment - Unlikely to misinterpret with the presence of an interpreter for accurate communication.
Question 2 of 5
The nurse is examining a preschool-aged child. What approach should the nurse use?
Correct Answer: B
Rationale: The correct answer is B because reassuring and providing feedback throughout the exam helps build trust and comfort with the child, making the exam less daunting. This approach fosters a positive therapeutic relationship and allows the child to feel supported and understood. Choice A may overwhelm the child with unnecessary information. Choice C may hinder the nurse's ability to conduct a thorough examination. Choice D is inappropriate and may cause distress to the child.
Question 3 of 5
When assessing an older adult, which vital sign changes occur with aging?
Correct Answer: B
Rationale: The correct answer is B: Widened pulse pressure. As people age, their blood vessels become less elastic, leading to an increase in systolic blood pressure and a decrease in diastolic blood pressure. This results in a widened pulse pressure. A: Increase in pulse rate is not a typical vital sign change with aging. C: Increase in body temperature is not a common vital sign change in older adults. D: Decrease in diastolic blood pressure is true but does not fully capture the overall vital sign changes that occur with aging.
Question 4 of 5
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Placing the cuff on the arm and inflating it 30 mm Hg above the point where the palpated pulse disappears ensures accurate blood pressure measurement. 2. This method is based on the auscultatory method, where the nurse listens for the Korotkoff sounds to determine systolic and diastolic pressures. 3. Inflating the cuff too high (Option B) can result in inaccurate readings, while inflating it based on the pulse rate (Option A) is not as reliable as using the disappearance of pulse method. 4. Option D is incorrect as it suggests inflating the cuff based on previous readings, which may not reflect the current blood pressure status of the patient.
Question 5 of 5
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
Correct Answer: D
Rationale: The correct answer is D. The dermis layer of the skin contains sensory receptors, such as Meissner's corpuscles and Pacinian corpuscles, which are responsible for detecting touch, pressure, temperature, and pain. This information is crucial for the nursing staff to understand as it impacts patient care and assessment. Choice A is incorrect because fat cells are predominantly found in the subcutaneous tissue, not in the dermis layer. Choice B is incorrect because keratin is primarily found in the epidermis, not the dermis. Choice C is incorrect because the dermis is not replaced every 4 weeks; it is a relatively stable layer compared to the epidermis, which undergoes continuous renewal.