ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurses best response?
Correct Answer: A
Rationale: Convection involves heat loss through air movement, such as a fan blowing cool air over the body. Turning off the fan directly addresses this by reducing airflow, minimizing heat dissipation. Removing an ice pack relates to conduction, not convection, as it involves direct contact rather than air movement. Reducing the room temperature might affect evaporation or overall comfort but doesnt target convection specifically. Increasing the room temperature could influence evaporation or radiation but doesnt stop the convective process caused by moving air. Choice A is the best response because it aligns with the mechanism of convection, where warm air around the body is replaced by cooler moving air. This intervention is practical and effective in a clinical setting, reflecting the nurses understanding of heat loss principles and patient thermoregulation.
Question 2 of 5
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
Correct Answer: C
Rationale: In deteriorating patients, carotid provides a strong, accessible pulse, reliable even in low perfusion, unlike radial or brachial . Popliteal is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.
Question 3 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.
Question 4 of 5
When taking a blood pressure, it is best practice to...
Correct Answer: C
Rationale: Best practice places the BP cuff on bare skin, upper arm above the elbow , ensuring accurate artery compression. Thick clothing muffles sounds. Crossed legs may elevate readings. Forearm is less reliable. Choice C is correct, per AHA guidelines, critical for nurses to obtain precise BP measurements avoiding common errors.
Question 5 of 5
The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8°F (36°C), whereas at 4 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?
Correct Answer: B
Rationale: Temperature drops at night (96.8°F) due to circadian rhythm, a normal variation from 98.6°F daytime. Infection isn't indicated. Blanket or meds are unnecessary without symptoms. Choice B is correct, per nursing knowledge of diurnal fluctuations.