ATI RN
Assessing Vital Signs Questions
Question 1 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 2 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 3 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.
Question 4 of 5
During an examination of a child, the nurse considers that physical growth is the best index of a child's:
Correct Answer: A
Rationale: The correct answer is A: General health. Physical growth is a reflection of overall health status in children. Adequate growth indicates proper nutrition, absence of chronic illness, and normal development. Monitoring growth parameters like height and weight can provide valuable insights into a child's well-being. The other choices are incorrect because while genetics (B) can influence growth potential, it doesn't directly indicate the current health status. Nutritional status (C) is important for growth but doesn't encompass all aspects of health. Activity and exercise patterns (D) are important for overall health but don't solely determine a child's general health status.
Question 5 of 5
A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is:
Correct Answer: C
Rationale: The correct answer is C because it accurately explains that the top number (systolic pressure) reflects the pressure in the arteries when the heart contracts. This is important information as it indicates the maximum pressure exerted on the arteries during a heartbeat. The bottom number represents diastolic pressure, which is the pressure in the arteries when the heart is at rest between beats. This information helps assess overall cardiovascular health. Choice A is incorrect because just stating the numbers are normal does not provide any educational value to the patient. Choice B is incorrect as it inaccurately describes the diastolic pressure. Choice D is incorrect as it simplifies the explanation and focuses on the wrong aspect of blood pressure.