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 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 2 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 3 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.
Question 4 of 5
A nurse is caring for a group of patients. Which patient will the nurse see first?
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler , adolescent , and adult values are normal for context. Choice A is correct, per triage prioritizing potential instability.
Question 5 of 5
Vital signs are measurements of...
Correct Answer: A
Rationale: Vital signs measure essential physiological functionstemperature, pulse, respiration, blood pressure, and oxygen saturationreflecting the body's basic operations . Urination frequency isn't a vital sign, though it's monitored in specific contexts. Weight and height are anthropometric, not vital signs. BMI is a calculated health indicator, not a direct measurement. Choice A is correct, aligning with nursing fundamentals defining vital signs as core indicators of life-sustaining processes, routinely assessed to evaluate health status and detect deviations requiring intervention.