ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing a neurological assessment and observes that the patient has difficulty with rapid alternating movements. What condition does this finding suggest?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar dysfunction. Difficulty with rapid alternating movements is a classic sign of cerebellar dysfunction due to the cerebellum's role in coordinating smooth and coordinated movements. This finding suggests impairment in the cerebellum's ability to control motor function, leading to problems with coordination and rapid movements. Peripheral neuropathy (B) primarily affects sensory and motor functions in the peripheral nervous system, not specifically rapid alternating movements. Motor weakness (C) refers to a generalized decrease in muscle strength and is not specific to rapid alternating movements. An upper motor neuron lesion (D) typically presents with spasticity and weakness but does not specifically affect rapid alternating movements as seen in cerebellar dysfunction.
Question 2 of 5
Shivering and piloerection are forms of:
Correct Answer: B
Rationale: Heat production, is correct because shivering (muscle contractions) and piloerection (goosebumps trapping air) generate and retain heat to raise body temperature. Heat loss, is opposite (e.g., sweating). Environmental temperature, is a condition, not a process. Fever, is a state, not the mechanism. When cold, the hypothalamus triggers these responses: shivering burns calories, producing heat; piloerection insulates. Together, they combat hypothermia, distinct from fevers systemic rise. Nursing recognizes them as compensatory actions in cold stress, supporting B as the precise answer based on physiological roles.
Question 3 of 5
Which of the following statements accurately describe the types of equipment that are used to assess temperature?
Correct Answer: B
Rationale: Temperature equipment varies by site and type. Blunt bulbs on nonmercury thermometers enhance safety, which is true. Axillary readings are typically 1°F lower than oral (e.g., 97.6°F vs. 98.6°F), a standard adjustment, making B correct. Rectal temperatures are 1°F higher than oral, also true, but the answer key specifies B. Nasal oxygen (D replaced with E) doesn't affect oral readings, unlike masks, which is accurate. Since the key lists B, it's supported by the consistent physiological difference between axillary and oral sites, a fundamental nursing concept for accurate temperature interpretation.
Question 4 of 5
The patient with heart failure is restless with a temperature of 102.2°F (39°C). Which action will the nurse take?
Correct Answer: A
Rationale: Heart failure with fever (102.2°F) and restlessness suggests increased oxygen demand. Applying oxygen addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing is irrelevant without respiratory symptoms. Restricting fluids may worsen dehydration in fever. Increasing metabolic rate exacerbates stress. Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.
Question 5 of 5
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
Correct Answer: A
Rationale: Temperature varies by route —e.g., rectal is 1°F higher, axillary 1°F lower than oral—requiring documentation for accuracy. Not all are core . Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.