ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
Which of the following conditions would produce a hyperresonant percussion note?
Correct Answer: A
Rationale: The correct answer is A: Large pneumothorax. A hyperresonant percussion note indicates excessive air in the chest cavity, leading to increased resonance. In a large pneumothorax, air fills the pleural space, causing the affected lung to collapse and creating a hyperresonant sound upon percussion. Lobar pneumonia (B) typically produces dullness due to consolidation of lung tissue. Pleural effusion (C) results in dullness as well, caused by fluid accumulation in the pleural space. Empyema (D) refers to pus in the pleural space, causing dullness rather than hyperresonance.
Question 2 of 5
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, 'I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!' Which of these responses by the nurse uses empathy?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Response C acknowledges the mother's feelings without judgment, showing understanding and empathy. 2. It validates her emotions by acknowledging the difficulty she is facing. 3. It does not assume or imply any specific emotion, allowing the mother to express herself freely. 4. Responses A and B are close but do not fully capture the depth of empathy displayed in response C. 5. Response D lacks empathy as it focuses more on agreement rather than truly understanding and validating the mother's emotions.
Question 3 of 5
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
Correct Answer: B
Rationale: The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.
Question 4 of 5
The nurse is examining a school-age child. Which approach is best?
Correct Answer: B
Rationale: The correct answer is B because involving the child in the process and explaining equipment helps build trust, reduces anxiety, and promotes cooperation. This approach empowers the child, respects their autonomy, and facilitates a positive healthcare experience. Choice A is incorrect as rushing the examination may increase the child's anxiety. Choice C is incorrect as having a parent present can provide comfort and support. Choice D is incorrect as the focus should be on the child for effective assessment and communication.
Question 5 of 5
When assessing a patient's pulse, the nurse should also notice which of these characteristics?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Force of pulse indicates strength, reflecting cardiac output. 2. It is crucial to assess force to identify abnormalities like weak or bounding pulses. 3. Force helps in diagnosing conditions like heart failure or shock. 4. Pallor, capillary refill, and timing do not directly relate to pulse strength. Summary: A: Force is correct as it reflects cardiac output. B: Pallor is incorrect as it pertains to skin color. C: Capillary refill time is incorrect as it assesses peripheral perfusion. D: Timing in the cardiac cycle is incorrect as it focuses on heart rhythm.