ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Correct Answer: D
Rationale: The correct answer is D because the older adult man's statement about joining his wife in heaven and planning to use a gun indicates specific intent and means for suicide. This combination of intent and method poses the highest risk for an imminent suicide attempt. Choice A is incorrect because joking about death does not necessarily indicate a high risk for suicide. Choice B, while concerning, refers to a past suicide attempt and does not provide current information to suggest an imminent risk. Choice C, although expressing suicidal ideation, lacks a clear plan or intent.
Question 2 of 5
Before auscultating the abdomen for bowel sounds, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because checking the room temperature and ensuring patient comfort is crucial before auscultating the abdomen to prevent any environmental factors from affecting the patient's comfort or bowel sounds. A, warming the stethoscope, is unnecessary and could potentially be uncomfortable for the patient. B, leaving the gown on, may interfere with the ability to properly listen to bowel sounds. C, ensuring the bell side of the stethoscope is on, is important but not the primary consideration before auscultating the abdomen.
Question 3 of 5
During auscultation, the nurse hears an unfamiliar sound. The best action is to:
Correct Answer: B
Rationale: The correct answer is B because asking another nurse to double-check the finding is crucial for validation and ensuring accuracy in assessment. This step helps in confirming the unfamiliar sound and ruling out any potential errors or misinterpretations. It promotes patient safety and effective communication among healthcare providers. Ignoring the sound (Choice A) can lead to overlooking a significant finding that may impact the patient's condition. Documenting and continuing the assessment (Choice C) without validation may result in incomplete information and potential misdiagnosis. Repositioning the patient and listening again (Choice D) may not address the need for confirmation from another healthcare provider.
Question 4 of 5
Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
Correct Answer: A
Rationale: The correct technique is to count the radial pulse for 1 minute if the rhythm is irregular because irregular rhythms may have fluctuations that can affect accuracy. Counting for a full minute provides a more comprehensive assessment of the pulse rate. Choice B is incorrect because multiplying the count by 4 after 15 seconds may not accurately reflect the pulse rate if the rhythm is irregular. Choice C is incorrect because counting for 2 full minutes is unnecessary and can be time-consuming without providing additional benefits in most cases. Choice D is incorrect as multiplying by 6 after 10 seconds is not suitable for irregular rhythms or for patients with cardiac abnormalities.
Question 5 of 5
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
Correct Answer: C
Rationale: Rationale: Acromegaly is a condition caused by excessive growth hormone production, leading to overgrowth of bones in the face, head, hands, and feet. This results in characteristic features such as enlarged facial bones, hands, and feet. The correct answer is C because it aligns with the typical assessment findings in acromegaly. Summary of other choices: A (Heavy, flattened facial features): This is not consistent with acromegaly, as the condition is characterized by overgrowth of bone rather than flattened features. B (Growth retardation and a delayed onset of puberty): These findings are more indicative of growth hormone deficiency rather than excess, which is seen in acromegaly. D (Increased height and weight and delayed sexual development): While increased height and weight may occur, delayed sexual development is not a common feature of acromegaly.