ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
Correct Answer: C
Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This test assesses new memory by asking the patient to remember and recall four unrelated words after a short delay. This is an effective way to specifically target the assessment of new memory function. Administering the FACT test (A) may assess different cognitive functions, not specifically new memory. Asking the patient to describe his first job (B) tests long-term memory, not new memory. Asking about the television show (D) before coming to the clinic does not directly assess new memory.
Question 2 of 5
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
Correct Answer: A
Rationale: The correct answer is A: Consider this a normal finding. The liver typically produces a dull sound upon percussion due to its solid nature. This is considered a normal finding as the liver is a solid organ. Palpation for an underlying mass (Choice B) is not necessary based solely on the dull percussion sound. Repositioning hands and percussing again (Choice C) is unlikely to change the result. Referring the patient for additional treatment (Choice D) is premature without further assessment. Therefore, A is the correct choice based on the expected percussion sound over the liver.
Question 3 of 5
The nurse is assessing an older adult. Which action is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Minimize position changes during the exam. This is the most appropriate action because older adults may have mobility issues, so minimizing position changes helps prevent discomfort and potential injury. Speaking loudly (choice C) is not necessary unless the patient has hearing impairments. Completing the exam in one session (choice A) may be overwhelming and tiring for the patient. Performing a quick exam (choice D) may compromise the thoroughness of the assessment.
Question 4 of 5
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
Correct Answer: B
Rationale: The correct answer is B because leaving the thermometer in place for 3 to 4 minutes allows for an accurate reading of oral temperature. This duration ensures the mercury in the thermometer reaches equilibrium with the body temperature. Choice A is incorrect as waiting 30 minutes after ingesting hot or iced liquids is unnecessary for assessing oral temperature. Choice C is incorrect as placing the thermometer in front of the tongue and asking the patient to close their lips may not provide an accurate reading. Choice D is incorrect as shaking the thermometer down before taking the temperature is not necessary and can introduce errors in the reading.
Question 5 of 5
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
Correct Answer: A
Rationale: The correct answer is A because in infants, it is recommended to measure respirations first, followed by pulse and temperature. Infants have irregular breathing patterns, so measuring respirations first allows for the most accurate reading. Pulse and temperature can be affected by handling the infant, so they should be measured after respirations. Choice B is incorrect because vital signs in infants are typically measured at the same frequency as in adults, unless there are specific concerns or conditions. Choice C is incorrect because involving the parent in the procedure and encouraging the infant to handle the equipment may not be appropriate or necessary for measuring vital signs accurately. Choice D is incorrect because it is not necessary to perform a physical examination before measuring vital signs in an infant. It is important to follow the standard sequence of measuring respirations, then pulse, and temperature for accurate readings.