ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Which of the following is true of the HPV vaccine?
Correct Answer: D
Rationale: The correct answer is D because the HPV vaccine can protect against anogenital lesions by preventing infection with certain HPV types. This is supported by clinical evidence and research. Choice A is incorrect because the vaccine can be administered at any age, not just within 3 years of first intercourse. Choice B is incorrect as the HPV vaccine covers against specific HPV types, not all. Choice C is incorrect as the vaccine is primarily used for prevention, not as adjuvant therapy in cervical cancer.
Question 2 of 5
You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be?
Correct Answer: C
Rationale: The correct answer is C: Press on his sternum and spine simultaneously. This action is known as the sternum and spine test, which helps determine if there is rib fracture. It is important to examine for instability and crepitus, which are indicative of rib fractures. This step is crucial in assessing the severity of the injury and deciding on the next course of action. Calling a medevac helicopter (A) or driving him to the city (B) without proper assessment can worsen the injury. Examining for tenderness over the injured area (D) is not specific for rib fractures and may not provide enough information to make a proper decision.
Question 3 of 5
A patient repeatedly seems to have difficulty coming up with a word. He says, 'I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. Circumlocution refers to the use of indirect or roundabout ways of expressing oneself, often due to difficulty in finding the right word. In this case, the patient struggles to recall the word "elevator" and instead describes it as "the thing that you step into that goes up in the air." This behavior is characteristic of circumlocution. Blocking (A) refers to a sudden interruption in train of thought or speech production, which is not evident in this scenario. Neologism (B) is the creation of new words or phrases, which is not demonstrated here. Circumstantiality (D) involves unnecessary and excessive detail in conversation, which is not the primary issue in this case.
Question 4 of 5
During a visit to the clinic, a patient states, 'The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?' The nurse's most appropriate response in this case would be:
Correct Answer: B
Rationale: The correct answer is B: "Would you like some information about the different ways a person can quit smoking?" Rationale: 1. Empathy: This response shows empathy by acknowledging the patient's struggle and offering support. 2. Patient-Centered Care: By asking if the patient would like information, the nurse involves the patient in decision-making. 3. Education: Providing information about quitting smoking empowers the patient to make an informed choice. 4. Non-judgmental: This response avoids judgment or pressure, which can help the patient feel more comfortable seeking help. Summary of Incorrect Choices: A: This response is directive and lacks empathy, potentially making the patient feel judged or pressured. C: While empathetic, this response does not offer practical help or information to address the patient's concerns. D: This response is confrontational and assumes the patient should already know about the smoking cessation program, which may come across as dismissive.
Question 5 of 5
During auscultation of the heart, the nurse hears a murmur. What instrument should be used to further assess this murmur?
Correct Answer: B
Rationale: The correct answer is B: Bell of the stethoscope. The bell of the stethoscope is used to assess low-frequency sounds like heart murmurs. Murmurs are often soft and low-pitched, requiring the bell for optimal detection. The diaphragm (Choice A) is used for high-frequency sounds. The electrocardiogram (Choice C) records the heart's electrical activity, not the physical sounds. The Doppler device (Choice D) is used to assess blood flow and velocity, not heart sounds. Therefore, the bell of the stethoscope is the appropriate instrument to further assess the heart murmur.