ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
Which groups body temperature changes more rapidly in response to both heat and cold air temperatures?
Correct Answer: A
Rationale: Infants and children, is correct because their higher surface-area-to-mass ratio and immature thermoregulation cause rapid temperature shifts. Infants lack shivering efficiency and sweat less, while childrens thin skin and high metabolism amplify responses to heat/cold. Older adults, adapt slowly due to reduced metabolism and circulation. Women, and Men, vary less by sex than age. Pediatric nursing notes infants can drop to hypothermia or spike to hyperthermia fastere.g., a cold room lowers temperature in minutes. This vulnerability requires close monitoring, making A the precise answer per developmental physiology.
Question 2 of 5
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral is unreliable with agitation. Rectal risks injury or vagal stimulation. Axillary is slow and less accurate. Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.
Question 3 of 5
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next?
Correct Answer: D
Rationale: In this scenario, option D, which is to retake the blood pressure personally and assess the patient's condition, is the correct choice. It is crucial for the nurse to directly reassess the vital sign in question to ensure accuracy and to promptly evaluate the patient's overall status. This action allows the nurse to verify the NAP's findings and make informed clinical decisions based on the most current and accurate data available. Option A, asking the NAP to retake the blood pressure, may not provide the immediate assessment and intervention needed for a potentially critical situation. Option B, instructing the NAP to assess the patient's other vital signs, delays direct evaluation of the concerning vital sign and may overlook the urgency of the situation. Option C, disregarding the low blood pressure report until the next scheduled check, is inappropriate as it could lead to a delay in addressing a possible deterioration in the patient's condition. From an educational perspective, this question emphasizes the importance of timely and accurate vital signs assessment in nursing practice. It highlights the responsibility of the nurse to personally verify critical findings, ensuring patient safety and quality care. This scenario also underscores the need for effective communication and collaboration within the healthcare team to address and respond to abnormal findings promptly.
Question 4 of 5
The blood pressure is...
Correct Answer: A
Rationale: Blood pressure is the force of blood against artery walls , measured as systolic and diastolic pressures. Blood volume influences it but isn't the definition. Heartbeats define pulse, not BP. ‘All' is incorrect. Choice A is correct, per cardiovascular nursing principles, distinguishing BP as a pressure metric critical for assessing circulation and organ perfusion.
Question 5 of 5
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C (148/82, 148/78, 134/86) because hypertension is defined as persistently elevated blood pressure readings. The average of the three readings in option C is significantly higher compared to the other options, indicating consistently elevated blood pressure levels. This pattern suggests a need for referral to a healthcare provider for further evaluation and management of hypertension. Option A (120/80, 118/78, 124/82) falls within the normal range for blood pressure readings, showing no significant elevation that would warrant immediate referral for hypertension evaluation. Option B (128/84, 124/86, 128/88) also shows readings within the prehypertensive range, not meeting the criteria for hypertension referral based on the blood pressure values provided. Option D (154/78, 118/76, 126/84) includes one high reading but the overall pattern does not demonstrate consistent elevation across all readings, unlike option C. This inconsistency does not meet the criteria for referral for hypertension evaluation. Educationally, understanding the significance of consistent blood pressure elevation is crucial for healthcare providers as it helps in identifying individuals who may require further assessment and intervention to manage hypertension effectively. Regular monitoring and appropriate referrals based on accurate assessment of blood pressure readings are essential in preventing the complications associated with uncontrolled hypertension.