ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's lungs and hears a pleural friction rub. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Pleuritis. A pleural friction rub is caused by inflammation of the pleura, the lining of the lungs and chest cavity. This rubbing together of inflamed surfaces creates a characteristic grating sound. Pleuritis is the most likely cause of this finding because it directly involves the pleura. Pneumonia (A) typically presents with crackles or decreased breath sounds. Pulmonary embolism (C) usually manifests with sudden onset chest pain and shortness of breath. Chronic obstructive pulmonary disease (D) may present with wheezing or prolonged expiration but not a pleural friction rub.
Question 2 of 5
Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurses best response?
Correct Answer: A
Rationale: Convection involves heat loss through air movement, such as a fan blowing cool air over the body. Turning off the fan directly addresses this by reducing airflow, minimizing heat dissipation. Removing an ice pack relates to conduction, not convection, as it involves direct contact rather than air movement. Reducing the room temperature might affect evaporation or overall comfort but doesnt target convection specifically. Increasing the room temperature could influence evaporation or radiation but doesnt stop the convective process caused by moving air. Choice A is the best response because it aligns with the mechanism of convection, where warm air around the body is replaced by cooler moving air. This intervention is practical and effective in a clinical setting, reflecting the nurses understanding of heat loss principles and patient thermoregulation.
Question 3 of 5
A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of the following age groups would this be considered a normal reading?
Correct Answer: A
Rationale: Pulse rates vary by age. Newborns have a normal range of 120-170 beats/min, so 170 is within limits. A ten-year-old ranges from 70-110, making 170 tachycardic. Adolescents range 60-100, and adults 60-100, both far below 170. Choice A is correct as newborns' high metabolic rate and immature cardiovascular system allow such elevated pulses, a normal finding in neonatal assessments per pediatric norms.
Question 4 of 5
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
Correct Answer: C
Rationale: In deteriorating patients, carotid provides a strong, accessible pulse, reliable even in low perfusion, unlike radial or brachial . Popliteal is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.
Question 5 of 5
The five primary vital signs routinely monitored by both caregivers and medical professionals and highlighted in this training, include the following:
Correct Answer: D
Rationale: The five primary vital signs are body temperature, blood pressure, heart rate (pulse), respiratory rate, and oxygen saturation . Weight and height/BMI (B, C) are additional metrics, not core vital signs. Choice D is correct, listing the standard set monitored in clinical practice, per nursing and medical guidelines (e.g., WHO, ANA), essential for comprehensive patient assessment and detecting acute changes.