ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
Correct Answer: D
Rationale: The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.
Question 2 of 5
The nurse should measure rectal temperatures in which of these patients?
Correct Answer: C
Rationale: The correct answer is C because rectal temperatures are most accurate in patients who are unable to hold a thermometer in their mouth, such as comatose adults. Rectal temperatures closely reflect core body temperature. Choice A (school-age child) may be able to hold a thermometer in their mouth. Choice B (older adult) may have conditions affecting rectal tissue. Choice D (patient receiving oxygen by nasal cannula) may have altered oxygen levels affecting temperature readings.
Question 3 of 5
The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:
Correct Answer: B
Rationale: The correct answer is B: Yield a falsely high blood pressure. Using a standard-sized cuff on an obese patient will lead to inaccurate readings because the cuff will not fit properly around the arm. This can result in increased pressure on the brachial artery, leading to a falsely high blood pressure reading. The other choices are incorrect because: A: Using a standard cuff on an obese patient will result in a falsely high, not low, blood pressure reading. C: The cuff size plays a significant role in blood pressure accuracy, so the reading will not be the same with a standard-sized cuff. D: While technique can impact blood pressure readings, in this scenario, the inaccurate reading is primarily due to the incorrect cuff size, not the technique of the person performing the assessment.
Question 4 of 5
When checking for proper blood pressure cuff size, which guideline is correct?
Correct Answer: D
Rationale: The correct answer is D because the width of the rubber bladder should ideally be around 40% of the arm circumference for proper blood pressure measurement. This is crucial for accurate readings as using a cuff that is too narrow or too wide can lead to incorrect readings. Option A is incorrect as one size does not fit all. Option B is incorrect as the length of the bladder is not the key factor. Option C is incorrect as the width of the bladder should be around 40%, not 80%, of the arm circumference.
Question 5 of 5
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
Correct Answer: B
Rationale: The correct answer is B: Dry mucous membranes and cracked lips. Dehydration leads to reduced moisture in the body, resulting in dryness of mucous membranes and lips. This is a sign of fluid imbalance and severe dehydration. Smooth mucous membranes (choice A) may indicate adequate hydration. Pale mucous membranes (choice C) could suggest anemia or poor perfusion, not solely dehydration. White patches on mucous membranes (choice D) are usually associated with fungal infections, not dehydration.