ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature?
Correct Answer: B
Rationale: Step 1: The correct answer is B: Dorsal surface of the hand; the skin is thinner on this surface than on the palms. Step 2: The dorsal surface of the hand has thinner skin, allowing for better sensitivity to temperature changes. Step 3: Thinner skin on the dorsal surface allows for more accurate assessment of subtle temperature variations. Step 4: Fingertips (choice A) are more sensitive to texture, not temperature. Ulnar portion (choice C) does not have enhanced temperature sensitivity. Palmar surface (choice D) is not the most sensitive to temperature variations. Summary: Choice B is correct because the dorsal surface of the hand offers better temperature sensitivity due to its thinner skin compared to other parts of the hand. Choices A, C, and D are incorrect as they do not provide the optimal location for assessing skin temperature.
Question 2 of 5
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
Correct Answer: C
Rationale: Certainly! The correct answer is C: Diurnal cycle. Body temperature follows a circadian rhythm, peaking in the late afternoon and reaching its lowest point in the early morning. This cycle is influenced by the body's internal clock and is independent of external factors. A: Constipation does not directly influence body temperature. B: While emotions can affect body temperature temporarily, they are not a consistent factor influencing overall body temperature. D: Nocturnal cycle refers to nighttime activities and does not specifically impact body temperature regulation.
Question 3 of 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Correct Answer: A
Rationale: Step 1: The phase I Korotkoff sounds mark the systolic blood pressure (SBP). In this case, they begin at 200 mm Hg. Step 2: The phase V Korotkoff sounds mark the diastolic blood pressure (DBP). In this case, they disappear at 92 mm Hg. Step 3: Therefore, the blood pressure reading is recorded as SBP/DBP. So, the correct recording for this patient would be 200/92 mm Hg. Summary: Choice A is correct as it accurately reflects the SBP and DBP values observed during auscultation. Choices B, C, and D are incorrect because they either include additional or incorrect values for SBP and DBP.
Question 4 of 5
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
Correct Answer: C
Rationale: The correct answer is C because a newborn's skin is more permeable than that of an adult, making them more susceptible to fluid loss. This is due to the thinner and less developed skin barrier in newborns, which can lead to increased transepidermal water loss. A: Subcutaneous fat deposits being high in the newborn would actually help with insulation and temperature regulation, reducing the risk of fluid loss. B: Sebaceous glands being overproductive in the newborn would contribute to skin lubrication and protection, not fluid loss. D: The presence of vernix caseosa helps to protect the infant's skin and prevent excessive fluid loss, so an increase in vernix caseosa would not lead to fluid loss.
Question 5 of 5
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and 'stuck on' his skin. Which is the best prediction?
Correct Answer: D
Rationale: The correct answer is D: Seborrheic keratoses, which do not become cancerous. Seborrheic keratoses are benign skin growths that are typically greasy, dark, and have a 'stuck on' appearance. They are not cancerous and do not pose a risk of developing into skin cancer. This is important to reassure the patient and alleviate their concerns. A: Senile lentigines are also known as age spots and are benign pigmented spots that do not typically become cancerous. B: Actinic keratoses are precancerous lesions that can develop into squamous cell carcinoma if left untreated. C: Acrochordons, also known as skin tags, are benign growths and not precursors to squamous cell carcinoma. In summary, the other choices are incorrect because they either refer to benign conditions that do not become cancerous (A and C) or precancerous lesions that can progress to skin cancer (