ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse has used interpretation regarding a patient's statement or actions. After using this technique, it would be best for the nurse to:
Correct Answer: B
Rationale: The correct answer is B because allowing time for the patient to confirm or correct the inference is essential after using interpretation. This step promotes effective communication by giving the patient the opportunity to clarify their intentions or feelings. It shows respect for the patient's perspective and encourages open dialogue. Apologizing (choice A) may not be necessary if interpretation is done respectfully. Continuing with the interview (choice C) without addressing the interpretation can hinder rapport. Immediately restating the conclusion (choice D) without seeking confirmation may lead to misunderstandings. In summary, choice B promotes patient-centered care and ensures accurate communication.
Question 2 of 5
The nurse is performing a general survey. Which action is a component of the general survey?
Correct Answer: A
Rationale: The correct answer is A because observing the patient's body stature and nutritional status is a key component of the general survey, which involves assessing the overall appearance and health status of the patient. This step provides valuable information about the patient's overall well-being and can help identify any potential health issues. Choice B is incorrect because interpreting subjective information reported by the patient is part of the health history, not the general survey. Choice C is incorrect because measuring vital signs (temperature, pulse, respirations, and blood pressure) is part of the physical assessment, not the general survey. Choice D is incorrect because observing specific body systems while performing the physical assessment is also not part of the general survey, but rather a focused assessment on particular body systems.
Question 3 of 5
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
Correct Answer: C
Rationale: Rationale: Choice C is correct because the force of a pulse is a reflection of the heart's stroke volume. The pulse strength is directly proportional to the volume of blood ejected by the heart with each beat. This means that a strong pulse indicates a larger stroke volume, while a weak pulse indicates a smaller stroke volume. Choices A, B, and D are incorrect because pulse strength is not typically recorded on a 0- to 2-point scale, does not directly demonstrate elasticity of the vessel wall, and is not solely a reflection of blood volume in the arteries during diastole.
Question 4 of 5
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
Correct Answer: C
Rationale: The correct answer is C: Systolic blood pressure may be falsely low. An auscultatory gap is a silent interval between the Korotkoff sounds during blood pressure measurement, commonly seen in hypertension. If the nurse does not check for an auscultatory gap, they may miss this silent interval, leading to an underestimation of the systolic blood pressure. Choices A and B are incorrect because missing an auscultatory gap does not affect the ability to hear diastolic blood pressure or result in a falsely low diastolic reading. Choice D is incorrect as missing an auscultatory gap would not lead to a falsely high systolic blood pressure.
Question 5 of 5
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
Correct Answer: C
Rationale: The correct answer is C: Distended veins. When a patient has been confined with his feet down for an extended period, it can lead to venous pooling in the lower extremities, causing the veins to become distended. This occurs due to decreased venous return and increased pressure in the veins. Pallor, coolness, and prolonged capillary filling time would not be expected findings in this situation as they are more indicative of arterial insufficiency or decreased perfusion, which is not the primary concern in this scenario. Distended veins are a common manifestation of venous stasis, making it the most appropriate choice in this context.