ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse is examining a preschool-aged child. What approach should the nurse use?
Correct Answer: B
Rationale: The correct answer is B because reassuring and providing feedback throughout the exam helps build trust and comfort with the child, making the exam less daunting. This approach fosters a positive therapeutic relationship and allows the child to feel supported and understood. Choice A may overwhelm the child with unnecessary information. Choice C may hinder the nurse's ability to conduct a thorough examination. Choice D is inappropriate and may cause distress to the child.
Question 2 of 5
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Placing the cuff on the arm and inflating it 30 mm Hg above the point where the palpated pulse disappears ensures accurate blood pressure measurement. 2. This method is based on the auscultatory method, where the nurse listens for the Korotkoff sounds to determine systolic and diastolic pressures. 3. Inflating the cuff too high (Option B) can result in inaccurate readings, while inflating it based on the pulse rate (Option A) is not as reliable as using the disappearance of pulse method. 4. Option D is incorrect as it suggests inflating the cuff based on previous readings, which may not reflect the current blood pressure status of the patient.
Question 3 of 5
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
Correct Answer: D
Rationale: The correct answer is D. The dermis layer of the skin contains sensory receptors, such as Meissner's corpuscles and Pacinian corpuscles, which are responsible for detecting touch, pressure, temperature, and pain. This information is crucial for the nursing staff to understand as it impacts patient care and assessment. Choice A is incorrect because fat cells are predominantly found in the subcutaneous tissue, not in the dermis layer. Choice B is incorrect because keratin is primarily found in the epidermis, not the dermis. Choice C is incorrect because the dermis is not replaced every 4 weeks; it is a relatively stable layer compared to the epidermis, which undergoes continuous renewal.
Question 4 of 5
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:
Correct Answer: D
Rationale: The correct answer is D: Cutis marmorata. Cutis marmorata is a transient mottling of the skin that occurs in response to cold temperatures, common in newborns with Down syndrome. This occurs due to immature vasomotor control and resolves with warmth. Choice A, Café au lait, refers to light brown skin pigmentation and is not related to mottling. Choice B, Carotenemia, is yellow-orange discoloration of the skin from excessive carotene intake, not related to mottling. Choice C, Acrocyanosis, is bluish discoloration of the extremities due to poor circulation, not mottling.
Question 5 of 5
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails?
Correct Answer: C
Rationale: The correct answer is C: Pitting. Pitting of the fingernails is a common finding in patients with severe psoriasis due to the involvement of nail matrix. It presents as small depressions or holes on the nail surface. This occurs as a result of abnormal keratinization in the nail matrix. Splinter hemorrhages (choice A) are seen in conditions like infective endocarditis, not psoriasis. Paronychia (choice B) is an infection around the nail fold. Beau lines (choice D) are transverse depressions in the nail plate caused by temporary disruption in nail growth, often due to systemic illness.