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: Failed to generate a rationale of 500+ characters after 5 retries.
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: Failed to generate a rationale of 500+ characters after 5 retries.
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.