ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is caring for a patient who has an elevated temperature. The nurse understands that
Correct Answer: D
Rationale: Hyperthermia is excessive heat production , unlike fever (set-point shift, C). They differ . Heat loss isn't the issue. Choice D is correct, per nursing pathophysiology distinguishing hyperthermia's uncontrolled rise from fever's regulated response.
Question 2 of 5
A nurse is assessing a client's blood pressure and finds it to be different in the two arms. What action should the nurse take?
Correct Answer: C
Rationale: A BP difference between arms may indicate vascular issues; reporting to the provider is priority. It's not normal . Rechecking or arm raising doesn't address the cause. Choice C is correct, per the explanation, ensuring timely evaluation.
Question 3 of 5
Which of the following patients should have their vital signs monitored at least every 4 hours?
Correct Answer: B
Rationale: A patient hospitalized for high blood pressure requires vital signs every 4 hours to monitor hypertension's impact and treatment efficacy, per acute care protocols. Critical care patients need more frequent checks (e.g., hourly). Long-term care residents (C, D) typically have stable conditions, requiring less frequent monitoring unless specified. The answer key selects B, reflecting nursing prioritization of acute conditions like hypertension over chronic or critical states, ensuring timely intervention for potential complications.
Question 4 of 5
A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?
Correct Answer: A
Rationale: Systolic pressure is the top number (140), measuring arterial pressure during heart contraction, per the answer key. Diastolic is the bottom (86), pulse pressure the difference, and hypotension a conditionnot terms for 140. Nurses document this per BP standards.
Question 5 of 5
A nurse is using inspection as an assessment technique. What does the nurse use during inspection?
Correct Answer: D
Rationale: Inspection uses vision, hearing, and smell , per the answer key, to observe without tools. Stethoscopes are for auscultation, hands percussion, palpation touch. Nurses, per Taylor, rely on senses for initial assessment data.