ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
The nurse is assessing a patient's cranial nerve function and asks the patient to close their eyes and smile. Which cranial nerve is being tested?
Correct Answer: B
Rationale: The correct answer is B) Cranial nerve VII (facial nerve). When the nurse asks the patient to close their eyes and smile, they are testing the function of the facial nerve, which controls the muscles of facial expression. By closing the eyes and smiling, the nurse is assessing the patient's ability to perform these facial movements controlled by cranial nerve VII. Option A) Cranial nerve V (trigeminal nerve) is responsible for sensory innervation of the face, but it does not control facial movements like closing the eyes and smiling. Option C) Cranial nerve IX (glossopharyngeal nerve) is involved in swallowing and taste sensation, not facial movements. Option D) Cranial nerve X (vagus nerve) is responsible for autonomic functions like heart rate and digestion, not facial movements. Understanding the function of each cranial nerve is crucial for healthcare professionals, especially nurses, as it helps in accurate assessment and diagnosis of various neurological conditions. Testing cranial nerve function provides valuable information about the patient's overall neurological status and helps in determining appropriate interventions.
Question 2 of 5
The nurse is performing a neurological assessment and asks the patient to close their eyes and distinguish between sharp and dull sensations. Which cranial nerve is being tested?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Cranial nerve V (trigeminal nerve). The trigeminal nerve is responsible for sensory functions in the face, including the ability to perceive sharp and dull sensations. When the nurse asks the patient to distinguish between sharp and dull sensations with their eyes closed, they are testing the sensory function of the trigeminal nerve. Option B) Cranial nerve VII (facial nerve) is responsible for facial expressions and taste sensation, not for sharp and dull sensations. Option C) Cranial nerve IX (glossopharyngeal nerve) is involved in taste sensation at the back of the tongue and throat, as well as in swallowing and salivation, but not in distinguishing between sharp and dull sensations. Option D) Cranial nerve X (vagus nerve) is primarily responsible for regulating autonomic functions in the body, such as heart rate and digestion, and is not involved in sensory perception in the face. Understanding the functions of each cranial nerve is crucial for healthcare professionals, especially nurses, as it helps in performing accurate neurological assessments and identifying any abnormalities or deficits in patients. Testing cranial nerve functions is an essential part of a comprehensive neurological assessment to ensure the overall health and well-being of the patient.
Question 3 of 5
When obtaining an oral temperature, after requesting the patient to open the mouth, the probe is gently inserted into:
Correct Answer: D
Rationale: Posterior sublingual pocket, is correct because this is the optimal site for accurate oral temperature measurement. Located under the tongue near the sublingual arteries, it reflects core body temperature due to rich blood supply. Anterior sublingual cavity, is too close to the mouths front, where air exposure lowers readings. Lateral sublingual density, is vague and not a recognized anatomical term. Superior lingual mucosity, incorrectly suggests the tongues upper surface, which is not used. The posterior sublingual pocket ensures the probe is secure and insulated, minimizing external influence. Nursing protocols emphasize placing the probe deep under the tongue and instructing the patient to close their mouth, supporting D as the precise location for reliable results.
Question 4 of 5
While taking an adult patients pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
Correct Answer: D
Rationale: A pulse rate of 140 beats/min in an adult is tachycardic (normal range: 60-100 beats/min), indicating a potential emergency requiring prompt action. Waiting 2 hours delays intervention for an abnormal finding that could signal distress, such as pain or arrhythmia. Checking blood pressure is useful but secondary to reporting, as it doesnt address the immediate need for oversight. Recording the information is part of documentation but insufficient alone for an abnormal rate. Reporting to the primary care provider is the best next step, ensuring timely evaluation and management of the underlying cause, such as dehydration, fever, or cardiac issues. This aligns with nursing protocols to escalate significant deviations from normal vital signs, prioritizing patient safety and interdisciplinary collaboration.
Question 5 of 5
On assessment, a nurse notes that a patient's pulse is weak and applying light pressure causes it to disappear. What pulse amplitude would the nurse document on the flow chart?
Correct Answer: B
Rationale: Pulse amplitude is graded 0-4+. A weak pulse disappearing with light pressure suggests low strength. 1+ is thready, barely palpable, not matching weak.' 2+ is normal but can be weak and obliterated with pressure, fitting here. 3+ is strong, and 4+ bounding, both too robust. Choice B (corrected from key's A) aligns with clinical description, as weak' typically starts at 2+ and fades easily, per nursing assessment standards.