ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
Regulator of body temperature:
Correct Answer: C
Rationale: The hypothalamus is the primary regulator of body temperature, making Choice C correct. Located in the brain, the hypothalamus acts as the bodys thermostat, receiving input from thermoreceptors and initiating responses like sweating or shivering to maintain a stable core temperature around 98.6°F (37°C). Medulla, is incorrect because the medulla oblongata primarily controls autonomic functions like heart rate and breathing, not temperature regulation. Sebaceous glands, refers to oil-producing skin glands with no role in temperature control. Wernickes area, is a brain region involved in language comprehension, unrelated to thermoregulation. The hypothalamus integrates signals from the body and environment, adjusting heat production and loss via mechanisms like vasodilation or muscle activity. Its critical role in homeostasis distinguishes it from the other options, confirming C as the correct answer supported by physiological evidence.
Question 2 of 5
A nurse teaching a student nurse how to take temperatures with a nonmercury glass thermometer would be correct in stating the following:
Correct Answer: C
Rationale: Teaching nonmercury glass thermometer use involves technique precision. Wiping from fingers to bulb ensures cleanliness but risks contamination downward. Shaking to 92°F is incorrect; it should reset below 96°F. Reading horizontally at eye level with rotation is accurate for visibility, making it correct. Leaving it for 3 minutes varies by site (oral 3, rectal 2-3, axillary 5-10) and protocol, so it's imprecise. Choice C is best as it details a universal, correct reading method, critical for student learning and accurate temperature assessment in clinical practice.
Question 3 of 5
What is the primary purpose of pulse assessment?
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status , reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure relates but requires a cuff. Temperature isn't pulse-related. Respiratory status is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
Question 4 of 5
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 . Muffling (70) is phase IV, not standard for adults. 138/70 uses muffling incorrectly. 70/62 is invalid. 138/70/62 isn't standard. Choice B is correct, per AHA guidelines.
Question 5 of 5
Hypothermia is defined as ...
Correct Answer: B
Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.