ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
Sudden, painful unilateral loss of vision may be caused by which of the following conditions?
Correct Answer: D
Rationale: The correct answer is D: Optic neuritis. Optic neuritis causes sudden, painful unilateral vision loss due to inflammation of the optic nerve. This condition often presents with reduced visual acuity, color vision changes, and afferent pupillary defect. Vitreous hemorrhage (A) typically causes painless vision loss, while central retinal artery occlusion (B) results in sudden painless vision loss. Macular degeneration (C) usually causes gradual central vision loss without pain.
Question 2 of 5
You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial insufficiency. You perform the Allen test. This means that you:
Correct Answer: C
Rationale: The correct answer is C: Checked for patency of the ulnar artery. The Allen test is used to assess the collateral circulation of the hand before arterial blood sampling from the radial artery. This involves occluding both the ulnar and radial arteries and then releasing pressure on the ulnar artery while observing the return of color to the hand. If the ulnar artery is patent, the hand should regain color within 5-10 seconds, indicating adequate collateral circulation. This is important to prevent ischemic complications. Choice A (Checked for patency of the radial artery) is incorrect because the Allen test specifically evaluates the ulnar artery's patency, not the radial artery. Choice B (Checked for patency of the brachial artery) is incorrect because the Allen test focuses on the collateral circulation in the hand, not the brachial artery. Choice D (Checked for patency of the femoral artery) is incorrect because the Allen test is not used to assess the femoral artery
Question 3 of 5
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Correct Answer: D
Rationale: The correct answer is D. Calling the physician immediately is crucial because a severe headache in a client with a cerebral aneurysm may indicate a rupture, a life-threatening emergency. The physician needs to be notified promptly for urgent intervention. Reassessing the client in 15 minutes (Choice A) may delay necessary action. Administering an analgesic (Choice B) without knowing the underlying cause of the headache could mask symptoms and delay appropriate treatment. Informing the nurse manager (Choice C) is not the priority; direct communication with the physician for immediate medical intervention is essential in this situation.
Question 4 of 5
The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?
Correct Answer: B
Rationale: The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement. A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results. C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size. D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.
Question 5 of 5
In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.