ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
The nurse is performing an abdominal examination and detects a bruit over the aorta. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The presence of a bruit over the aorta during an abdominal examination is most likely associated with an Aortic Aneurysm. Aneurysms can cause turbulent blood flow resulting in a bruit. Aortic aneurysm is a common location for this finding due to the dilation of the aorta. Renal artery stenosis, pneumonia, and pancreatitis are not typically associated with a bruit over the aorta, making them incorrect choices.
Question 2 of 5
Which of the following values for vital signs would the nurse address first?
Correct Answer: B
Rationale: Oxygen saturation of 89%, is correct because its the most urgent. Normal oxygen saturation is 95-100%; 89% indicates hypoxemia, risking tissue damage and requiring immediate intervention (e.g., oxygen therapy). Temperature of 99°F, is slightly elevated but not critical. Respirations of 28, is high (normal 12-20), but less acute without context like distress. BP 160/89, suggests stage 1 hypertension, concerning but not immediately life-threatening. Nurses prioritize airway, breathing, and circulation (ABCs); low oxygen saturation directly impairs oxygenation, making B the top priority for swift action to prevent complications like organ failure.
Question 3 of 5
A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:
Correct Answer: C
Rationale: In a blood pressure of 120/80 mmHg, 120 is the systolic pressure, the highest pressure on arterial walls during ventricular contraction . The diastolic (80) is the lowest pressure during relaxation . Pulse pressure is the difference , here 40 mmHg. The rhythmic distention describes the pulse, not a specific reading. Choice C is correct, reflecting the systolic phase of the cardiac cycle, a fundamental concept in vital sign interpretation.
Question 4 of 5
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse reflects cardiac response but isn't directly hypothalamic. Respirations may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
Question 5 of 5
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?
Correct Answer: B
Rationale: The correct answer is B) It has no risk of injury to patient or nurse. Rationale: Utilizing a temporal artery thermometer in assessing the temperature of newborns and children is a safe practice because it poses no risk of injury to both the patient and the nurse. This is crucial when dealing with vulnerable populations like infants, where safety is a top priority. Option A) It is not affected by skin moisture: This option is incorrect because while temporal artery thermometers are less affected by skin moisture compared to other methods, they can still be influenced by excessive moisture, which might affect the accuracy of the temperature reading. Option C) It reflects rapid changes in radiant temperature: This option is incorrect as temporal artery thermometers are known for providing a reliable temperature reading but not specifically for reflecting rapid changes in radiant temperature. Option D) It is accurate even when the forehead is covered with hair: This option is incorrect because temporal artery thermometers may provide inaccurate readings if the forehead is covered with hair, as the hair can interfere with the sensor's contact with the skin. Educational context: Understanding the rationale behind choosing specific temperature assessment methods is crucial for nurses to ensure accurate and safe patient care. Temporal artery thermometers are often preferred for newborns and children due to their non-invasive nature and safety profile, making them a suitable option for this population. Nurses should be knowledgeable about the advantages and limitations of different temperature assessment methods to make informed decisions in clinical practice.