ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger and then touch the nurse's finger. Which aspect of neurological function is being tested?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar function and coordination. This task, known as the finger-to-nose test, assesses the coordination and accuracy of movements controlled by the cerebellum. When the patient is asked to touch their nose and then the nurse's finger, any inaccuracies or tremors in movement indicate cerebellar dysfunction. Choice B is incorrect as cranial nerve function is not specifically tested in this task. Choice C is incorrect as proprioception, the sense of body position and movement, is not the primary focus of this test. Choice D is incorrect as memory is not being directly assessed in this task.
Question 2 of 5
The normal temperature for an adult is:
Correct Answer: B
Rationale: 37 degrees Celsius (oral), is correct as it equals 98.6°F, the standard adult oral temperature. Axillary ( 37°C) is higher than typical (~36.6°C). 36°C oral, is too low (96.8°F). 37.7°C oral (99.9°F), suggests fever. Oral readings, taken sublingually, are 0.5°C below rectal (37.5°C-38.1°C) and 0.5°C above axillary (36.5°C-37°C), balancing accuracy and convenience. This norm, established by Wunderlich in the 19th century, remains a clinical benchmark, varying slightly by time of day or individual. Nursing relies on 37°C oral for baseline health, making B the accurate choice per physiological standards.
Question 3 of 5
A patient informs the nurse that she still uses a mercury thermometer to take the temperature of her children when they are sick. Which of the following is a recommended teaching guideline for patients using these types of thermometers?
Correct Answer: C
Rationale: Mercury thermometers pose risks due to toxicity if broken, making patient education vital. Encouraging alternative devices like digital thermometers is a proactive, safe recommendation, reducing exposure risk while maintaining functionality. Teaching safety about breakage is useful but incomplete without promoting alternatives. Telling patients to discard mercury thermometers in the trash is unsafe, as mercury requires special disposal, not regular waste. Restricting use to hospitals is impractical and ignores home needs. Choice C is correct because it aligns with public health guidelines (e.g., CDC) to phase out mercury thermometers, offering a practical, safe solution for home use, enhancing family safety and modernizing care practices.
Question 4 of 5
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer essential. A stethoscope assesses heart/lung sounds, not temperature. A blood pressure cuff or sphygmomanometer measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.
Question 5 of 5
The nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
Correct Answer: B
Rationale: Light-headedness, irregular pulse, and a BP drop (100/72 from 113/80) suggest instability (e.g., arrhythmia). Notifying the provider ensures prompt evaluation. More pressure won't clarify irregularity. Dismissing symptoms or delaying risks deterioration. Choice B is correct, per nursing escalation protocols.