ATI RN
Assess Vital Signs Questions
Question 1 of 5
When performing a physical assessment, the first technique the nurse will always use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. When performing a physical assessment, inspection is always the first technique used as it provides an overall view of the patient's appearance and any obvious abnormalities. This includes observing skin color, posture, gait, facial expressions, and any visible signs of distress. Inspection helps the nurse gather initial information before proceeding to palpation, percussion, and auscultation. Palpation (A) involves using touch to assess areas such as texture, temperature, and tenderness. Percussion (C) is tapping on the body to produce sounds that indicate the location, size, and density of underlying structures. Auscultation (D) is listening to sounds produced by the body using a stethoscope. These techniques are important in a comprehensive physical assessment but come after inspection.
Question 2 of 5
When assessing an older adult, which vital sign changes occur with aging?
Correct Answer: B
Rationale: The correct answer is B: Widened pulse pressure. As people age, their blood vessels become less elastic, leading to an increase in systolic blood pressure and a decrease in diastolic blood pressure. This results in a widened pulse pressure. A: Increase in pulse rate is not a typical vital sign change with aging. C: Increase in body temperature is not a common vital sign change in older adults. D: Decrease in diastolic blood pressure is true but does not fully capture the overall vital sign changes that occur with aging.
Question 3 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 4 of 5
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
Correct Answer: D
Rationale: The correct answer is D. The dermis layer of the skin contains sensory receptors, such as Meissner's corpuscles and Pacinian corpuscles, which are responsible for detecting touch, pressure, temperature, and pain. This information is crucial for the nursing staff to understand as it impacts patient care and assessment. Choice A is incorrect because fat cells are predominantly found in the subcutaneous tissue, not in the dermis layer. Choice B is incorrect because keratin is primarily found in the epidermis, not the dermis. Choice C is incorrect because the dermis is not replaced every 4 weeks; it is a relatively stable layer compared to the epidermis, which undergoes continuous renewal.
Question 5 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.