ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg sign is a test of proprioception. A positive Romberg sign indicates impaired proprioception, where the patient is unable to maintain balance with eyes closed due to dysfunction in proprioceptive pathways. This is the correct answer (C). Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar ataxia presents with a different set of symptoms. Choice D is incorrect as sensory neuropathy affects sensation, not proprioception.
Question 2 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg test evaluates a person's ability to maintain balance with eyes closed. A positive Romberg sign indicates proprioceptive dysfunction, as the patient relies on visual input for balance. This suggests issues with sensory perception and coordination. Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar dysfunction would present with different signs. Choice D is incorrect as motor weakness would not be specifically indicated by a positive Romberg sign.
Question 3 of 5
Core temperatures are not measured at:
Correct Answer: D
Rationale: Sublingual site, is correct because it measures oral temperature, considered a surface reading, not a true core site. Core temperature reflects internal body heat (e.g., 98.6°F-100.4°F) and is taken at sites like Tympanic site (ear, near hypothalamus), Rectal site (most accurate), and Bladder (via catheter). Sublingual (under tongue) readings, while reliable, are slightly lower (~98.6°F) and influenced by air or food, making them non-core. Nursing distinguishes core for critical monitoring (e.g., hypothermia) versus surface for routine checks. Thus, D is the accurate choice, aligning with thermometry standards and physiological definitions.
Question 4 of 5
A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his mother's legs and asking to go home. Which of the following would be the best nursing intervention to accomplish this task?
Correct Answer: B
Rationale: A restless toddler clinging to the mother is likely anxious, making vital sign assessment challenging. Performing assessments with the child on the parent's lap provides comfort and stability, increasing cooperation and accuracy. Doing blood pressure first may heighten fear, as it involves a cuff that can feel restrictive, worsening the situation. Hiding instruments might reduce initial anxiety but doesn't address ongoing distress during measurement. Removing distractions could help focus but may not calm the child as effectively as parental presence. Choice B is best because it leverages the mother's comforting role, a proven pediatric nursing strategy to ease anxiety and facilitate procedures. This approach aligns with developmental considerations, prioritizing the child's emotional security to obtain reliable vital signs.
Question 5 of 5
The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap conserves heat by covering this key area, a standard neonatal practice. A diaper alone offers minimal coverage, increasing heat loss. Doubling clothing helps but is less effective than a cap for head protection. Raising the room to 90°F risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.