ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Placing the cuff on the arm and inflating it 30 mm Hg above the point where the palpated pulse disappears ensures accurate blood pressure measurement. 2. This method is based on the auscultatory method, where the nurse listens for the Korotkoff sounds to determine systolic and diastolic pressures. 3. Inflating the cuff too high (Option B) can result in inaccurate readings, while inflating it based on the pulse rate (Option A) is not as reliable as using the disappearance of pulse method. 4. Option D is incorrect as it suggests inflating the cuff based on previous readings, which may not reflect the current blood pressure status of the patient.
Question 2 of 5
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:
Correct Answer: D
Rationale: The correct answer is D: Cutis marmorata. Cutis marmorata is a transient mottling of the skin that occurs in response to cold temperatures, common in newborns with Down syndrome. This occurs due to immature vasomotor control and resolves with warmth. Choice A, Café au lait, refers to light brown skin pigmentation and is not related to mottling. Choice B, Carotenemia, is yellow-orange discoloration of the skin from excessive carotene intake, not related to mottling. Choice C, Acrocyanosis, is bluish discoloration of the extremities due to poor circulation, not mottling.
Question 3 of 5
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails?
Correct Answer: C
Rationale: The correct answer is C: Pitting. Pitting of the fingernails is a common finding in patients with severe psoriasis due to the involvement of nail matrix. It presents as small depressions or holes on the nail surface. This occurs as a result of abnormal keratinization in the nail matrix. Splinter hemorrhages (choice A) are seen in conditions like infective endocarditis, not psoriasis. Paronychia (choice B) is an infection around the nail fold. Beau lines (choice D) are transverse depressions in the nail plate caused by temporary disruption in nail growth, often due to systemic illness.
Question 4 of 5
In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because performing the otoscopic examination at the end of the assessment allows the nurse to build rapport with the child first, reducing anxiety and increasing cooperation. This approach also prevents the child from becoming upset or uncooperative due to discomfort during the examination. Additionally, it ensures that the child's comfort and trust are prioritized during the assessment process. Choice A is incorrect because omitting the otoscopic examination based on the child having a fever can lead to missing important diagnostic information. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended practice and can cause discomfort to the child. Choice C is incorrect as it is important for the mother to be present to provide comfort and support to the child during the examination.
Question 5 of 5
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia is the difficulty or discomfort in swallowing, which can occur after a stroke due to facial muscle weakness. In this case, the right-sided facial drooping indicates a stroke affecting the left side of the brain, which can lead to dysphagia. Epistaxis (nosebleed) and rhinorrhea (runny nose) are not typically associated with facial drooping after a stroke. Xerostomia (dry mouth) is more related to salivary gland dysfunction and is not directly related to facial muscle weakness.