ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
The nurse is auscultating the lungs and hears a high-pitched sound during expiration. What does this finding most likely indicate?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Asthma. When a high-pitched sound is heard during expiration, it is indicative of wheezing, a common characteristic of asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to difficulty in breathing and wheezing sounds upon expiration. Option B) Chronic obstructive pulmonary disease (COPD) typically presents with wheezing during expiration as well, but the sound is often lower-pitched compared to asthma. COPD is characterized by progressive airflow limitation due to chronic bronchitis and/or emphysema. Option C) Pneumonia usually presents with crackles or fine crackling sounds upon auscultation, rather than high-pitched wheezing during expiration. Option D) Pulmonary edema typically manifests with crackles or moist sounds upon auscultation due to fluid accumulation in the lungs, and not high-pitched wheezing. In an educational context, understanding these different sounds and their associated conditions is crucial for nurses to accurately assess and differentiate respiratory issues in patients. By recognizing the distinct characteristics of each condition, nurses can provide appropriate interventions and therapies to manage and treat respiratory problems effectively.
Question 2 of 5
Core body temperature is highest at:
Correct Answer: C
Rationale: Late afternoon, is correct because core body temperature peaks around 4 pm to 6 pm due to circadian rhythms governed by the hypothalamus. It rises throughout the day from a low of ~97°F (4-6 am) to a high of ~98.6°F-100°F, reflecting increased metabolic activity. Early morning, is the nadir, not peak. Noon, is midway, not the highest. Evening, sees a decline post-peak. Studies show this diurnal pattern in healthy adults, with late afternoon aligning with maximal alertness and physical performance. Nurses consider this when assessing fevere.g., a 99°F reading at 5 pm might be normal variation. Thus, C is accurate based on physiological circadian evidence.
Question 3 of 5
A nurse notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurses response to the student?
Correct Answer: A
Rationale: A cuff too large underestimates blood pressure, leading to an incorrect reading , as it doesnt compress the artery properly. It wont cause significant injury or dangerous pressure , though a too-small cuff might. Korotkoff sounds remain audible but may be misread. Choice A is correct, emphasizing accuracy in measurement technique, a key teaching point for nursing students.
Question 4 of 5
The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection , where warm air around the body is replaced by cooler moving air. Radiation involves heat emission without contact, not fan-driven. Conduction requires direct contact (e.g., cold pack), not air movement. Evaporation involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
Question 5 of 5
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) 30 to 60. Newborn infants typically have a faster respiratory rate compared to older children and adults. A normal respiratory rate for a newborn is considered to be between 30 to 60 breaths per minute. Option B) 22 to 28 is more reflective of a normal respiratory rate for an older child or adult, and would be considered abnormal for a newborn. Option C) 16 to 20 is also within the range for an older child or adult, not a newborn. Option D) 10 to 15 is too low for a newborn and would indicate respiratory distress. Educationally, understanding the normal vital sign ranges for different age groups is crucial for healthcare professionals, especially for those working with newborns. This knowledge ensures appropriate assessment, early detection of potential issues, and timely intervention to promote the health and well-being of newborns. It also highlights the importance of individualized care based on age-specific physiological differences.