ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing a cardiovascular assessment and notes that the patient has a weak and thready pulse. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Step 1: A weak and thready pulse indicates poor perfusion due to decreased blood volume. Step 2: Hypovolemia refers to low blood volume, leading to a weak pulse. Step 3: Hypervolemia is an excess of blood volume, which would not cause a weak pulse. Step 4: Aortic stenosis affects the heart valves, not directly causing a weak pulse. Step 5: Peripheral artery disease results in decreased blood flow to extremities, not affecting the pulse in general. Conclusion: The correct answer is A (Hypovolemia) because it directly correlates with the presentation of a weak and thready pulse, while the other choices are not the primary cause of this finding.
Question 2 of 5
Which of the following statements about Fever is not true?
Correct Answer: D
Rationale: It does not do anything to defend the body, is not true and thus the correct answer. Fever, an elevated body temperature (also called pyrexia), is a defense mechanism against infection, enhancing immune responses like white blood cell activity and inhibiting pathogen growth. Fever is a sign of illness, is true, as it often signals infection or inflammation. It is the same as pyrexia or hyperthermia, is partially true; fever and pyrexia are synonymous, but hyperthermia (uncontrolled heat rise) differs. It is reflected through an increase of body temperature, is true by definition. Choice D is false because fever actively aids immunity, raising temperature to fight microbes, making it the statement that does not hold, per the questions intent.
Question 3 of 5
Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurses best response?
Correct Answer: A
Rationale: Convection involves heat loss through air movement, such as a fan blowing cool air over the body. Turning off the fan directly addresses this by reducing airflow, minimizing heat dissipation. Removing an ice pack relates to conduction, not convection, as it involves direct contact rather than air movement. Reducing the room temperature might affect evaporation or overall comfort but doesnt target convection specifically. Increasing the room temperature could influence evaporation or radiation but doesnt stop the convective process caused by moving air. Choice A is the best response because it aligns with the mechanism of convection, where warm air around the body is replaced by cooler moving air. This intervention is practical and effective in a clinical setting, reflecting the nurses understanding of heat loss principles and patient thermoregulation.
Question 4 of 5
A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of the following age groups would this be considered a normal reading?
Correct Answer: A
Rationale: Pulse rates vary by age. Newborns have a normal range of 120-170 beats/min, so 170 is within limits. A ten-year-old ranges from 70-110, making 170 tachycardic. Adolescents range 60-100, and adults 60-100, both far below 170. Choice A is correct as newborns' high metabolic rate and immature cardiovascular system allow such elevated pulses, a normal finding in neonatal assessments per pediatric norms.
Question 5 of 5
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
Correct Answer: C
Rationale: In deteriorating patients, carotid provides a strong, accessible pulse, reliable even in low perfusion, unlike radial or brachial . Popliteal is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.