ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
Correct Answer: B
Rationale: The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.
Question 2 of 5
When assessing a patient's pulse, the nurse should also notice which of these characteristics?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Force of pulse indicates strength, reflecting cardiac output. 2. It is crucial to assess force to identify abnormalities like weak or bounding pulses. 3. Force helps in diagnosing conditions like heart failure or shock. 4. Pallor, capillary refill, and timing do not directly relate to pulse strength. Summary: A: Force is correct as it reflects cardiac output. B: Pallor is incorrect as it pertains to skin color. C: Capillary refill time is incorrect as it assesses peripheral perfusion. D: Timing in the cardiac cycle is incorrect as it focuses on heart rhythm.
Question 3 of 5
The nurse is performing a general survey of a patient. Which finding is considered normal?
Correct Answer: D
Rationale: The correct answer is D because arm span equaling the patient's height is considered normal. This is known as the ape index, where arm span is equal to height. This finding indicates proportional body development. A is incorrect as a narrow base when standing is abnormal. B is incorrect as appearing older than stated age is abnormal. C is incorrect as arm span greater than height can indicate abnormal growth or a medical condition.
Question 4 of 5
The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's:
Correct Answer: B
Rationale: The correct answer is B: Circulatory status. A thorough skin assessment is important as the skin provides valuable information on blood flow, oxygenation, and perfusion. Changes in skin color, temperature, and integrity can indicate circulatory issues like poor perfusion or compromised circulation. Understanding the circulatory status is crucial for identifying potential health problems and providing appropriate interventions. The other choices (A, C, D) are incorrect as they do not directly correlate with the primary purpose of a skin assessment, which is to evaluate the health of the circulatory system.
Question 5 of 5
A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:
Correct Answer: D
Rationale: The correct answer is D: Trichotillomania; her child probably has a habit of absentmindedly twirling her hair. Trichotillomania is a psychological disorder characterized by the urge to pull out one's hair. In this case, the irregularly shaped patches with broken-off, stublike hair suggest hair pulling rather than a medical condition like folliculitis (A), traumatic alopecia (B), or tinea capitis (C). Folliculitis is a bacterial infection of hair follicles, not related to hair pulling. Traumatic alopecia is hair loss due to physical damage, not consistent with the described symptoms. Tinea capitis is a fungal infection causing hair loss and is not typically associated with broken-off, stublike hair. Trichotillomania is the most likely explanation given the presentation of the child's hair condition.