ATI RN
Assess Vital Signs Questions
Question 1 of 5
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
Correct Answer: D
Rationale: The correct answer is D because in an outpatient setting for cold and flu symptoms, a focused or problem-centered history is appropriate to quickly assess the current issue. Step 1: Identify the presenting problem - cold and flu symptoms. Step 2: Gather specific information related to the issue. Step 3: Focus on relevant history questions to determine the cause and appropriate intervention. Other choices are incorrect because they may require a comprehensive history for long-term care (A), immediate intervention for severe shortness of breath (B), or pre-operative assessment for surgery (C).
Question 2 of 5
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
Correct Answer: D
Rationale: The correct answer is D because ascites is fluid accumulation in the peritoneal cavity, causing a shifting dullness or fluid wave. Tympany that changes location with patient position (shifting dullness) is a classic finding in ascites, indicating the presence of fluid. Choices A, B, and C do not specifically indicate ascites. Bilateral flank tympany (choice A) is associated with bowel sounds, dullness that remains despite position change (choice B) may suggest a solid mass, and dullness centrally when supine (choice C) could be due to other abdominal organ enlargement.
Question 3 of 5
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A. The significant change in blood pressure from 128/68 to 160/50, along with a significant decrease in pulse from 110 to 55, and a decrease in respirations from 26 to 14, indicates potential signs of deteriorating condition. A drop in blood pressure paired with a significant decrease in pulse and respirations could signify shock, which is a life-threatening condition that requires immediate intervention. Option B shows an increase in pulse and respirations, but the blood pressure remains within an acceptable range. Option C shows a slight increase in blood pressure with minimal changes in pulse and respirations. Option D shows a moderate decrease in pulse and a significant increase in respirations, but the blood pressure remains relatively stable. In summary, option A is the most concerning as it shows a combination of significant changes in blood pressure, pulse, and respirations, indicating a potential deterioration in the patient's condition.
Question 4 of 5
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway using which method?
Correct Answer: C
Rationale: The correct answer is C: Jaw thrust maneuver. This method is used to open the airway in a suspected cervical spine injury. Step 1: Place hands on either side of the patient's face, positioning the thumbs under the jaw. Step 2: Use the thumbs to gently lift the jaw forward, keeping the head in a neutral position. This technique helps maintain alignment of the cervical spine. The other choices are incorrect because A: Flexed position may worsen spinal injury, B: Head tilt-chin lift can cause further trauma in cervical spine injury, and D: Modified head tilt-chin lift is not recommended for suspected spinal injuries.
Question 5 of 5
The nurse is performing a head-to-toe assessment. Which sequence of assessment techniques is correct for the abdominal region?
Correct Answer: C
Rationale: The correct sequence for assessing the abdominal region is inspection, auscultation, percussion, palpation (Choice C). Inspection allows visual assessment for any abnormalities. Auscultation should be done before palpation to prevent altering bowel sounds. Percussion helps assess for organ size and density. Palpation is done last to assess for tenderness, masses, and organ shape. Explanation for why the other choices are incorrect: A: Incorrect because palpation should be done after auscultation. B: Incorrect because auscultation should be done before palpation. D: Incorrect because palpation should be the last step in the sequence.