ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
Which of the following occurs in respiratory distress?
Correct Answer: B
Rationale: The correct answer is B because skin between the ribs moving inward with inspiration indicates increased work of breathing, a characteristic of respiratory distress. This is due to the increased effort needed to expand the chest cavity to inhale sufficient oxygen. Choices A, C, and D are incorrect because speaking in sentences of 10-20 words suggests adequate air exchange for speech, relaxed neck muscles are not indicative of distress, and leaning posteriorly is not a typical sign of respiratory distress.
Question 2 of 5
In using verbal responses to assist the patient's narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective. An example of a verbal response that focuses on the health care provider's perspective would be:
Correct Answer: D
Rationale: The correct answer is D: Confrontation. Confrontation is a verbal response that focuses on the health care provider's perspective by directly addressing discrepancies or inconsistencies in the patient's narrative. This technique helps challenge the patient's denial or resistance to change, promoting self-awareness and insight. In contrast, empathy (choice A) involves understanding and sharing the patient's feelings, reflection (choice B) involves restating or paraphrasing the patient's words, and facilitation (choice C) involves encouraging the patient to continue expressing their thoughts. These responses all focus on the patient's frame of reference, rather than challenging or addressing the provider's perspective.
Question 3 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. Bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child indicate normal resonance due to increased air content in the lungs. This finding is consistent with normal lung sounds in children of this age. Palpating for pain or tenderness (choice A) is not indicated as the percussion findings are normal. Asking the child to take shallow breaths (choice B) would not change the percussion findings. Immediate referral (choice C) is unnecessary as the percussion findings are within the normal range for a child of this age.
Question 4 of 5
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Correct Answer: B
Rationale: The correct answer is B because giving feedback and reassurance during the examination is appropriate for a 4-year-old child. This approach helps to build trust, reduce anxiety, and make the child feel more comfortable. Providing reassurance also helps the child understand what is happening and promotes cooperation during the examination. Explanation for other choices: A: Explaining procedures in detail may overwhelm and increase anxiety in a 4-year-old child. C: Avoiding asking the child to remove clothing may hinder a thorough examination and compromise the child's health. D: Performing a head-to-toe examination starting with the ears may not be developmentally appropriate or engaging for a 4-year-old child.
Question 5 of 5
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
Correct Answer: C
Rationale: The correct answer is C. The tympanic method reduces the risk of cross-contamination compared to rectal temperature measurement. This is because the tympanic thermometer does not come into direct contact with mucous membranes or bodily fluids, unlike rectal thermometers. Cross-contamination can occur when pathogens are transmitted between individuals or surfaces. Therefore, using the tympanic method decreases the chances of spreading infections. Choice A is incorrect as tympanic temperature measurement is quicker compared to rectal temperature measurement. Choice B is incorrect as the tympanic method is non-invasive and generally well-tolerated. Choice D is incorrect as the tympanic membrane reflects the temperature of the blood vessels in the temporal artery, not the ophthalmic artery.