ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B because when a patient experiences a nosebleed, sitting up with the head tilted forward and pinching the nose helps to apply pressure to the bleeding area, promoting clotting and stopping the bleeding. This position also prevents blood from flowing down the throat, which can cause choking or swallowing blood. Placing a cold compress while sitting up (choice A) can help constrict blood vessels, but the key action of applying pressure by pinching the nose is missing. Allowing bleeding to stop on its own (choice C) without taking any immediate action could lead to excessive blood loss. Lying on the back with the head tilted back (choice D) is not recommended as it can cause blood to flow back into the throat and potentially lead to aspiration.
Question 2 of 5
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _____ comparison.
Correct Answer: A
Rationale: The correct method is side-to-side comparison. This allows for a systematic approach by ensuring all areas are examined equally. Moving side-to-side helps to maintain consistency and accuracy in assessing lung sounds. Top-to-bottom, posterior-to-anterior, and interspace-by-interspace methods may lead to missed areas or confusion in tracking progress. Side-to-side comparison is the most effective technique for thorough auscultation.
Question 3 of 5
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:
Correct Answer: B
Rationale: The correct answer is B: Postnasal drip or sinusitis. This is because a cough that worsens at night but improves during the day is a common symptom of postnasal drip or sinusitis, where mucus drips down the back of the throat when lying down. Other choices are incorrect because pneumonia typically presents with a persistent cough throughout the day, exposure to irritants at work would not cause a cough pattern specific to nighttime, and chronic bronchial irritation from smoking would result in a more persistent and continuous cough regardless of the time of day.
Question 4 of 5
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?
Correct Answer: B
Rationale: The correct answer is B because breastfeeding provides the perfect nutrition and antibodies for the baby, promoting optimal growth and immunity. It is essential for the baby's health and development. Incorrect answers: A: Breastfed babies are not necessarily more colicky; this statement is misleading. C: Breastfed babies may feed more frequently initially but not necessarily throughout infancy. D: Breastfeeding may not come naturally to every woman, as it can be challenging for some due to various reasons.
Question 5 of 5
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
Correct Answer: A
Rationale: Step-by-step rationale: 1. During pregnancy, blood pressure tends to decrease due to hormonal and physiological changes. 2. The decline in blood pressure is attributed to peripheral vasodilatation, allowing for increased blood flow to the placenta. 3. This vasodilatation is a normal adaptive response to support the growing fetus. 4. The parasympathetic effect of pregnancy hormones contributes to the vasodilatation and helps regulate blood pressure. 5. Therefore, choice A is correct as it aligns with the physiological changes expected during pregnancy. Summary of other choices: - Choice B incorrectly attributes the decline solely to the parasympathetic effect, ignoring the role of vasodilatation. - Choice C is incorrect as a decrease in blood pressure does not necessarily mean a decrease in cardiac output during pregnancy. - Choice D is incorrect as a decrease in blood pressure does not always indicate a dangerous decrease in blood volume for the fetus.