ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl's mental status?
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential regression in the girl's social development, preferring to play with younger children. This behavior may suggest difficulty in forming age-appropriate relationships or social skills, which could be concerning in the context of her parents' divorce. Choice A may indicate attachment issues, but it is common for young children to cling to their primary caregiver in stressful situations. Choice B describes a common emotional response to stress but does not necessarily indicate a mental health concern. Choice C is a typical behavior for a 5-year-old and does not raise immediate concerns about her mental status.
Question 2 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 3 of 5
The nurse is examining a school-age child. Which approach is best?
Correct Answer: B
Rationale: The correct answer is B because involving the child in the process and explaining equipment helps build trust, reduces anxiety, and promotes cooperation. This approach empowers the child, respects their autonomy, and facilitates a positive healthcare experience. Choice A is incorrect as rushing the examination may increase the child's anxiety. Choice C is incorrect as having a parent present can provide comfort and support. Choice D is incorrect as the focus should be on the child for effective assessment and communication.
Question 4 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 5 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.