ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
Which of the following is the most effective type of transcutaneous electrical nerve stimulation (TENS) stimulator?
Correct Answer: B
Rationale: The correct answer is B: High frequency, low intensity. This type of TENS stimulator is most effective because high frequency helps to block pain signals from reaching the brain, while low intensity ensures safety and prevents muscle contractions. High frequency stimulates nerve fibers that inhibit pain transmission, providing relief without causing discomfort. A: High frequency, high intensity can be too harsh and may lead to muscle contractions, causing discomfort. C: Low frequency, high intensity may not effectively block pain signals and can cause muscle contractions or discomfort. D: Low frequency, low intensity may not provide sufficient pain relief as it might not effectively block pain signals.
Question 2 of 5
A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely?
Correct Answer: D
Rationale: The correct answer is D: CN X lesion on the right. When the uvula deviates to the left upon touching the soft palate, it indicates a lesion of the right vagus nerve (CN X). The uvula is innervated by the vagus nerve, and when there is a lesion on the right side, the uvula will deviate away from the affected side due to the unopposed action of the intact left vagus nerve. Choices A and B are incorrect because cranial nerve IX (glossopharyngeal nerve) does not innervate the uvula. Choice C is incorrect as a lesion of the left vagus nerve would cause the uvula to deviate to the right, not the left.
Question 3 of 5
An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?
Correct Answer: C
Rationale: The correct answer is C: Ischemia. The elderly woman's history of coronary bypass surgery suggests a higher risk for vascular issues like mesenteric ischemia. The severe, diffuse abdominal pain that is not exacerbated by palpation is a classic presentation of mesenteric ischemia. This condition results from inadequate blood supply to the intestines and can lead to severe abdominal pain. Malingering (A) is unlikely as there is a legitimate medical history. Neuropathy (B) typically presents with different symptoms such as numbness or tingling rather than severe abdominal pain. Physical abuse (D) does not align with the clinical presentation and medical history.
Question 4 of 5
When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 92/42 mm Hg indicates hypotension, which can be a sign of septic shock in a patient with bacterial meningitis. This finding requires immediate attention as it can lead to serious complications and requires prompt intervention to stabilize the patient's hemodynamic status. A: A positive Kernig's sign and complaints of a stiff neck are common findings in patients with bacterial meningitis but do not require immediate reporting as they are expected symptoms. C: A temperature of 101°F is slightly elevated but not a critical finding that necessitates immediate reporting compared to hypotension.
Question 5 of 5
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Head turned to the side. This position can potentially increase intracranial pressure by obstructing venous drainage and impeding blood flow. The rationale is to maintain cerebral perfusion and reduce the risk of complications. A: Head midline is correct as it promotes proper alignment and reduces strain on the neck muscles. C: Neck in neutral position is correct to prevent additional pressure on the neck and optimize blood flow. D: Head of bed elevated 30 to 45 degrees is correct to facilitate venous drainage and reduce intracranial pressure.