ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
The nurse is performing a neurological assessment and asks the patient to close their eyes and distinguish between sharp and dull sensations. Which cranial nerve is being tested?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Cranial nerve V (trigeminal nerve). The trigeminal nerve is responsible for sensory functions in the face, including the ability to perceive sharp and dull sensations. When the nurse asks the patient to distinguish between sharp and dull sensations with their eyes closed, they are testing the sensory function of the trigeminal nerve. Option B) Cranial nerve VII (facial nerve) is responsible for facial expressions and taste sensation, not for sharp and dull sensations. Option C) Cranial nerve IX (glossopharyngeal nerve) is involved in taste sensation at the back of the tongue and throat, as well as in swallowing and salivation, but not in distinguishing between sharp and dull sensations. Option D) Cranial nerve X (vagus nerve) is primarily responsible for regulating autonomic functions in the body, such as heart rate and digestion, and is not involved in sensory perception in the face. Understanding the functions of each cranial nerve is crucial for healthcare professionals, especially nurses, as it helps in performing accurate neurological assessments and identifying any abnormalities or deficits in patients. Testing cranial nerve functions is an essential part of a comprehensive neurological assessment to ensure the overall health and well-being of the patient.
Question 2 of 5
While taking an adult patients pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
Correct Answer: D
Rationale: A pulse rate of 140 beats/min in an adult is tachycardic (normal range: 60-100 beats/min), indicating a potential emergency requiring prompt action. Waiting 2 hours delays intervention for an abnormal finding that could signal distress, such as pain or arrhythmia. Checking blood pressure is useful but secondary to reporting, as it doesnt address the immediate need for oversight. Recording the information is part of documentation but insufficient alone for an abnormal rate. Reporting to the primary care provider is the best next step, ensuring timely evaluation and management of the underlying cause, such as dehydration, fever, or cardiac issues. This aligns with nursing protocols to escalate significant deviations from normal vital signs, prioritizing patient safety and interdisciplinary collaboration.
Question 3 of 5
On assessment, a nurse notes that a patient's pulse is weak and applying light pressure causes it to disappear. What pulse amplitude would the nurse document on the flow chart?
Correct Answer: B
Rationale: Pulse amplitude is graded 0-4+. A weak pulse disappearing with light pressure suggests low strength. 1+ is thready, barely palpable, not matching weak.' 2+ is normal but can be weak and obliterated with pressure, fitting here. 3+ is strong, and 4+ bounding, both too robust. Choice B (corrected from key's A) aligns with clinical description, as weak' typically starts at 2+ and fades easily, per nursing assessment standards.
Question 4 of 5
The nurse needs to obtain an accurate respiratory rate from a patient who is talking with visitors. What will the nurse do?
Correct Answer: C
Rationale: In this scenario, option C, "Obtain without the patient knowing," is the correct choice for the nurse to obtain an accurate respiratory rate from a patient who is talking with visitors. It is essential to prioritize the accuracy of vital sign measurements to ensure patient safety and proper assessment. Choosing option A, "Tell the patient to continue talking," is incorrect because asking the patient to continue talking may disrupt the natural breathing pattern, leading to an inaccurate respiratory rate measurement. Option B, "Count respirations while the patient is talking," is also incorrect as the patient's talking can interfere with the nurse's ability to accurately count respirations. Option D, "Wait until the patient finishes talking," is not the best choice as it delays the assessment process, and the nurse may miss the opportunity to obtain an accurate respiratory rate promptly. Educationally, this question highlights the importance of accurate vital sign assessment and the need for healthcare professionals to adapt their techniques to ensure precision in data collection, even in challenging situations. It underscores the significance of patient assessment skills and the ability to prioritize patient care in real-world clinical settings.
Question 5 of 5
Variations in body temperature can be caused by...
Correct Answer: D
Rationale: Body temperature varies with exercise increasing it via metabolism, gender with slight differences (e.g., women post-ovulation), and cold fluids potentially lowering oral readings. All are factors. Choice D is correct, as nursing recognizes these influencesexercise raises heat production, gender affects baseline, and fluids alter local readingsrequiring context in temperature assessment to ensure accurate interpretation and care planning.