ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
Correct Answer: B
Rationale: Rationale: Option B is correct because gathering mental status information during the health history interview is a crucial and efficient way to assess a patient's mental state. Here's the rationale: 1. Mental status assessment during the health history interview allows for a comprehensive evaluation of the patient's current mental state. 2. It helps in identifying any immediate concerns or issues that may impact the patient's overall health and well-being. 3. Gathering mental status information early on can guide further assessment and interventions. 4. Conducting a separate mental status examination may be necessary in some cases, but integrating it into the health history interview streamlines the assessment process. In summary, option B is correct as it emphasizes the importance and efficiency of gathering mental status information during the health history interview, while the other choices provide inaccurate or irrelevant statements.
Question 2 of 5
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to 'warm up' and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Correct Answer: B
Rationale: The correct answer is B. Stopping down to the toddler's level and asking her about the toy she is holding is the best approach because it shows respect for the toddler's interests and allows for engagement on her terms, fostering a sense of trust and comfort. This approach acknowledges the toddler's autonomy and helps build a positive relationship. Option A is incorrect because tickling the toddler may not be appropriate and could potentially lead to discomfort or fear. Option C is incorrect as continuing to ignore the toddler may cause her to feel neglected and hinder the establishment of rapport. Option D is incorrect because it is important for the mother to be present to provide comfort and support during the examination.
Question 3 of 5
The nurse notes a drumlike percussion sound over the abdomen. This indicates:
Correct Answer: B
Rationale: The drumlike percussion sound over the abdomen suggests air-filled areas. This occurs because air in the stomach or intestines resonates when tapped, creating a hollow sound. This finding is consistent with conditions like gastric distention or bowel obstruction. Constipation (A) would not typically produce a drumlike sound. The presence of a tumor (C) or dense organs (D) would not lead to this specific percussion finding.
Question 4 of 5
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
Correct Answer: A
Rationale: The correct answer is A because a tympanic membrane thermometer provides rapid measurements, making it ideal for uncooperative younger children. This is crucial in clinical settings where quick and accurate temperature readings are necessary. Choice B is incorrect as the TMT may not be the most accurate method for newborn infants due to their delicate ear structure. Choice C is incorrect as TMT devices can be relatively expensive. Choice D is incorrect as studies may not strongly support the use of TMT in children under 6 years due to factors like accuracy and reliability.
Question 5 of 5
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
Correct Answer: B
Rationale: The correct answer is B: Detect the presence of an auscultatory gap. Performing a palpated pressure before auscultating blood pressure helps detect an auscultatory gap, which is a period of silence between the systolic and diastolic readings. This is important because relying solely on Korotkoff sounds may lead to missing this gap, resulting in inaccurate blood pressure readings. The other choices are incorrect because: A: More clearly hearing Korotkoff sounds is not the primary purpose of palpated pressure. C: Palpated pressure does not specifically help avoid missing a falsely elevated blood pressure. D: Identifying phase IV of Korotkoff sounds is not the main objective of performing palpated pressure.