ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
Some of the signs of respiratory distress are...
Correct Answer: D
Rationale: Respiratory distress includes grunting and nasal flaring as effort signs, raspy breathing from obstruction, and panicked look/sweating from stressall are indicators. Choice D is correct, as nurses identify these clinical signs per respiratory assessment protocols (e.g., PALS), prompting urgent intervention for airway or oxygenation problems.
Question 2 of 5
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Normal for an infant. The normal pulse rate for an infant typically ranges from 120 to 160 beats per minute. Infants have higher heart rates compared to older children and adults due to their smaller size and higher metabolic rate. This rapid heart rate is necessary to meet their body's oxygen and nutrient demands for growth and development. Option B) The proper rate for a toddler is incorrect because toddlers generally have slightly lower heart rates than infants, typically ranging from 80 to 130 beats per minute. Option C) Too slow for an infant is incorrect as a pulse rate of 145 beats per minute falls within the normal range for infants. Option D) The same as that of a normal adult is incorrect as the average resting heart rate for adults is between 60 to 100 beats per minute. Educationally, it is crucial for healthcare providers to understand the normal vital sign ranges for different age groups to accurately assess and monitor patients' health. Recognizing normal variations in vital signs based on age helps in early detection of potential health issues and prompts appropriate interventions. Regular assessment and understanding of vital signs are fundamental skills for healthcare professionals in providing safe and effective care to patients of all ages.
Question 3 of 5
A nurse is assessing a client's pulse rate and observes an irregular rhythm with skipped beats. What action should the nurse take?
Correct Answer: C
Rationale: Irregular rhythm with skipped beats suggests a potential arrhythmia, requiring provider notification for evaluation. It's not normal . Waiting an hour delays care. Deep breathing doesn't address cardiac issues. Choice C is correct, per the explanation, reflecting nursing's duty to escalate abnormal findings promptly for patient safety.
Question 4 of 5
A nurse is assessing a client's pain and decides to use the FLACC Pain Assessment Scale. Which population is this scale primarily designed for?
Correct Answer: C
Rationale: The FLACC Pain Assessment Scale is primarily designed for infants and young children. This scale is specifically tailored to assess pain in non-verbal or pre-verbal individuals who may have difficulty expressing their discomfort verbally. It consists of five categories: Face, Legs, Activity, Cry, and Consolability, each scored from 0 to 2. Infants and young children often exhibit pain through changes in facial expressions, body movements, and vocalizations, which the FLACC scale is designed to capture accurately. Option A, adults, is incorrect because adults are typically able to communicate their pain using words, making the FLACC scale less suitable for this population. Option B, older adults, may also be able to communicate their pain verbally or through other means better suited for adult pain assessment tools. Option D, individuals with cognitive impairment, could potentially benefit from the FLACC scale if they have difficulty communicating their pain effectively, but the primary target population for this scale remains infants and young children. In an educational context, it is crucial for healthcare providers, especially those working with pediatric patients, to be familiar with specialized pain assessment tools like the FLACC scale. Understanding the appropriate use of these scales ensures accurate and timely pain assessment in individuals who may not be able to verbalize their discomfort effectively. By recognizing the target population for each pain assessment tool, healthcare professionals can provide more individualized and effective care for their patients.
Question 5 of 5
Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) hemorrhage. When the body experiences hemorrhage or blood loss, there is a decrease in blood volume and subsequently a decrease in blood pressure. In response to this drop in blood pressure, the body releases antidiuretic hormone (ADH) from the posterior pituitary gland. ADH acts on the kidneys to promote water reabsorption, helping to increase blood volume and maintain blood pressure within normal limits. Option B) allergies, Option C) obesity, and Option D) asthma are incorrect in the context of releasing ADH due to hemorrhage. Allergies, obesity, and asthma do not directly impact blood volume or blood pressure in the same way as hemorrhage does. Therefore, they would not trigger the release of ADH from the posterior pituitary gland. Educationally, understanding the relationship between pathologic conditions and hormonal responses is crucial in healthcare settings. Nurses, medical assistants, and other healthcare professionals need to recognize the signs and symptoms of conditions that can affect vital signs and hormonal regulation to provide appropriate care and interventions. This knowledge also aids in interpreting changes in a patient's condition and adjusting care plans accordingly.