ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Correct Answer: D
Rationale: The correct answer is D. Calling the physician immediately is crucial because a severe headache in a client with a cerebral aneurysm may indicate a rupture, a life-threatening emergency. The physician needs to be notified promptly for urgent intervention. Reassessing the client in 15 minutes (Choice A) may delay necessary action. Administering an analgesic (Choice B) without knowing the underlying cause of the headache could mask symptoms and delay appropriate treatment. Informing the nurse manager (Choice C) is not the priority; direct communication with the physician for immediate medical intervention is essential in this situation.
Question 2 of 5
In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.
Question 3 of 5
A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?
Correct Answer: B
Rationale: The correct answer is B: Re-examine the patient and establish new goals. This is the most appropriate next step because if the patient has not shown progress in over three weeks, it indicates a need to reassess the current treatment plan and goals. By re-examining the patient, the therapist can identify any factors hindering progress and adjust the treatment plan accordingly. This proactive approach ensures the patient receives the most effective care. Choice A: Transferring the patient to another therapist does not address the root cause of the lack of progress and may disrupt continuity of care. Choice C: Simply continuing to modify the treatment plan without re-evaluating the patient may not lead to improved outcomes. Choice D: Alerting the referring physician should be done after reassessment and establishing new goals, as the physician may require updated information but is not the immediate next step.
Question 4 of 5
A physical therapist educates a patient on how to use a mechanical lift to transfer a family member from bed to a wheelchair. The therapist explains that the MOST important instruction for the caregiver is to:
Correct Answer: B
Rationale: The correct answer is B: Position the sling appropriately under the patient. This is crucial as an improperly positioned sling can lead to discomfort or injury for the patient during the transfer. By ensuring the sling is correctly placed, the caregiver can provide proper support and enhance the safety of the transfer. Placing the patient's arms outside of the sling (choice A) is important but not as critical as positioning the sling correctly. Locking the lift after positioning the patient in the wheelchair (choice C) is important for safety but not as crucial as ensuring the sling placement. Maintaining good body mechanics during the transfer (choice D) is also important for the caregiver's safety, but the priority should be on positioning the sling properly to ensure the patient's safety and comfort.
Question 5 of 5
A physical therapist evaluates a patient with suspected carpal tunnel syndrome. Which clinical test is MOST appropriate to confirm the diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. This test involves the patient flexing their wrists for 60 seconds to reproduce symptoms of carpal tunnel syndrome. This maneuver compresses the median nerve, causing numbness and tingling in the fingers. Phalen's test is specific for carpal tunnel syndrome. Other choices are not specific to this condition. Finkelstein test is for De Quervain's tenosynovitis, Tinel's sign at the elbow is for ulnar nerve entrapment, and Empty can test is for rotator cuff pathology.