ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing an abdominal assessment and notes that the patient has a distended abdomen with tympany on percussion. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Gastrointestinal obstruction. A distended abdomen with tympany on percussion is indicative of trapped air in the intestines, commonly seen in gastrointestinal obstruction. This occurs when there is a blockage in the intestines, causing gas to accumulate and result in the distension. Ascites (B) is the accumulation of fluid in the abdominal cavity, which would present with dullness on percussion, not tympany. Pancreatitis (C) and Hepatomegaly (D) typically do not present with tympany on percussion and are not likely to cause a distended abdomen with this specific finding.
Question 2 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 3 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 4 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.
Question 5 of 5
The five primary vital signs routinely monitored by both caregivers and medical professionals and highlighted in this training, include the following:
Correct Answer: D
Rationale: The five primary vital signs are body temperature, blood pressure, heart rate (pulse), respiratory rate, and oxygen saturation . Weight and height/BMI (B, C) are additional metrics, not core vital signs. Choice D is correct, listing the standard set monitored in clinical practice, per nursing and medical guidelines (e.g., WHO, ANA), essential for comprehensive patient assessment and detecting acute changes.