ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
Vital signs are based on....
Correct Answer: C
Rationale: Vital signs reflect homeostasis , the body's ability to maintain internal stability (e.g., temperature, heart rate). Food processing affects digestion, not vital signs directly. Weight and height inform growth or BMI, not homeostasis monitoring. ‘None of the above' dismisses the correct link. Choice C is correct, as vital signs are physiological markers of homeostatic balance, a principle nurses use to assess health and guide care, per basic pathophysiology.
Question 2 of 5
When focusing on temperature regulation of newborns and infants, the nurse understands that
Correct Answer: D
Rationale: In the context of newborns and infants, the correct answer is D) Newborns need to wear a cap to prevent heat loss. This is because newborns have a larger body surface area compared to their body mass, making them more prone to heat loss. Newborns have underdeveloped mechanisms for regulating their body temperature, such as shivering, vasoconstriction, and sweating. Therefore, they rely on external means to maintain their body temperature, including wearing a cap to prevent heat loss from their heads, which have a high surface area relative to the rest of their bodies. Option A) Temperatures are basically the same for infants and older adults is incorrect because infants have less developed temperature-regulating mechanisms compared to older adults. Infants are more susceptible to temperature fluctuations and have difficulty maintaining a stable body temperature. Option B) Infants have well-developed temperature-regulating mechanisms is incorrect as stated above; newborns and infants actually have underdeveloped temperature-regulating mechanisms, which is why they need external support to maintain their body temperature. Option C) The normal temperature range gradually increases as the person ages is incorrect because the normal temperature range remains relatively constant throughout the lifespan, typically around 98.6°F (37°C) for most individuals. Age does not directly correlate with an increase in the normal temperature range. Educationally, understanding the unique temperature regulation challenges faced by newborns and infants is crucial for healthcare providers to provide appropriate care and support to this vulnerable population. Ensuring appropriate clothing, environmental temperature, and interventions like wearing a cap can help prevent complications related to temperature instability in newborns.
Question 3 of 5
The nurse is caring for a newborn infant in the hospital nursery. She notices that the infant is breathing rapidly but is pink, warm, and dry. The nurse knows that the normal respiratory rate for a newborn is breaths per minute.
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) 30 to 60 breaths per minute. For newborn infants, a normal respiratory rate falls within this range. Newborns have a faster respiratory rate compared to older children and adults due to their smaller lung capacity and higher oxygen demand. Option B) 25 to 32 is incorrect as it falls below the normal range for a newborn. Option C) 16 to 19 is too low for a newborn infant's respiratory rate, and option D) 12 to 20 is also too low. Educationally, understanding normal vital sign ranges for different age groups is crucial for healthcare providers as it helps in identifying deviations from normal and potentially identifying underlying health issues. In the case of newborns, rapid breathing within the normal range could indicate various factors such as adaptation to the environment or minor respiratory distress. Regular monitoring and accurate assessment of vital signs are essential for providing appropriate care to newborns.
Question 4 of 5
A nurse is assessing a client's blood pressure and finds it to be 160/90 mmHg. What action should the nurse take?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is option C: Initiate antihypertensive medication. A blood pressure reading of 160/90 mmHg indicates hypertension, which is a serious condition that requires intervention to prevent complications such as heart disease, stroke, and kidney damage. Initiating antihypertensive medication is crucial to lower the blood pressure and reduce the risks associated with hypertension. Option A is incorrect because a blood pressure reading of 160/90 mmHg is not within the normal range. Option B of rechecking the blood pressure after 30 minutes is not appropriate when the reading is significantly high as in this case. Option D, instructing the client to increase salt intake, is also incorrect as it could further elevate blood pressure levels in hypertensive individuals. From an educational perspective, it is important for nurses to understand the significance of abnormal vital signs, such as elevated blood pressure, and the appropriate actions to take in such situations. Early detection and management of hypertension are key in preventing complications and promoting overall health and well-being. Nurses must be equipped with the knowledge and skills to recognize abnormal vital signs and intervene promptly to provide safe and effective care to their patients.
Question 5 of 5
A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?
Correct Answer: C
Rationale: In the context of a health assessment vital signs quizlet, selecting option C, which is to place the bell of the stethoscope over the brachial artery, is crucial for obtaining an accurate blood pressure reading. This action is correct because the brachial artery is the primary site for blood pressure measurement due to its proximity to the heart and its accessibility for auscultation. Placing the stethoscope over this artery allows the nurse to accurately hear the Korotkoff sounds, which are essential for determining systolic and diastolic blood pressure. Option A is incorrect because inflating the cuff to 20 mmHg above the estimated systolic pressure could lead to an inaccurate reading and discomfort for the patient. Option B is also incorrect as deflating the cuff at a rate of 10-20 mmHg per second is too rapid and may result in inaccurate measurements. Option D is incorrect as palpating the radial artery while auscultating for Korotkoff sounds is not necessary and may interfere with the accuracy of the blood pressure reading. In an educational setting, understanding the correct technique for measuring blood pressure using a manual sphygmomanometer and stethoscope is fundamental for nursing students. Emphasizing the importance of proper positioning of the stethoscope over the brachial artery helps ensure accurate blood pressure readings, which are vital for assessing a patient's cardiovascular health. Practicing this skill with attention to detail and precision is essential for providing quality patient care.