ATI VITAL SIGNS QUESTIONS AND
CORRECT SOLUTIONS
Vital aSigns a- a(correct aanswer) a-Measurements aof athe abody's amost abasic afunctions,
aincluding: atemperature
pulse
respiration a
blood apressure
oxygen asaturation
pain alevel
Temperature aRange afor aadults a- a(correct aanswer) a-Oral. a96.8---100.4 aF a(36--38 aC)
Rectal ausually a0.9 aF a(0.5 aC) adegrees ahigher athan aoral aor atympanic, acloser ato athe
abody acore atemperature.
Axillary ausually a0.9F a(0.5C) alower athan aoral aand atympanic atemperatures.
Temporal anearly a1 adegree aF a(0.5 aC) ahigher athan aoral, aand a2 adegrees aF a(1
adegree aC) ahigher athan aaxillary.
aa aclient's ausual atemperature aserves aas aa abaseline afor acomparison.
Heat aproduction a- a(correct aanswer) a-results afrom aincreases ain abasal ametabolic
arate, amuscle aactivity, athyroxine aoutput, atestosterone, aand asympathetic astimulation,
awhich aincreases aheat aproduction.
Heat aloss a- a(correct aanswer) a-occurs afrom:
Conduction: atransfer aof ahear afrom athe abody adirectly ato aanother asurface a( aex:
aimmersion ain awater)
Convection: aDispersion aof ahear aby aair acurrents a(ex: awind ablowing aacross askin)
Evaporation: aDispersion aof aheat athrough awater avapor a(perspiration).
Radiation: aTransfer aof aheat afrom aone aobject ato aanother aobject awithout acontact
abetween athem a(heat alost afrom athe abody ato aa acold aroom)
Diaphoresis: aVisible aperspiration aon athe askin.
Physiologic aresponses a(temperature) a- a(correct aanswer) a-The aneurologic aand
acardiovascular asystems awork atogether ato aregulate abody atemperature. aDisease aor
atrauma aof athe ahypothalamus aor aspinal acord awith aalter atemperature acontrol.
Pulse a- a(correct aanswer) a-the ameasurement aof athe aheart arate aand arhythm.
Pulse arate a- a(correct aanswer) a-the anumber aof atimes aper aminute ayou afeel aor ahear
athe apulse.
, Pulse arhythm a- a(correct aanswer) a-The aregularity aof aimpulses. aA apremature, alate aor
amissed aheart abeat acan aresult ain aan airregular ainterval abetween aimpulses aand acan
aindicate aaltered aelectrical aactivity aof athe aheart. aA aregular apulse ais athe aexpected
afinding.
expected aheart arate arange a- a(correct aanswer) a-for aan aadult aclient a60 ato a100 abeats
aper aminute aat arest.
assess athe awave alike asensations aor aimpulses ayou afeel ain aa aperipheral aarterial
avessel aor aover athe aapex aof athe aheart aas aa agauge aof acardiovascular astatus.
strength a(amplitude aor apulse avolume) a- a(correct aanswer) a-Reflects athe avolume aof
ablood aejected aagainst athe aarterial awall awith aeach aheart acontraction aand athe
acondition aof athe aarterial avascular asystem. athe astrength aof athe aimpulse ashould abe
athe asame afrom abeat ato abeat.
Graded aon aa ascale afrom a0 ato a4:
0 a= aAbsent, aunable ato apalpate
1+ a= aDiminished, aweaker athan aexpected
2+ a= aBrisk, aexpected
3+ a= aIncreased, astrong
4+ a= aFull avolume, abounding
Equality aof apulse a- a(correct aanswer) a--symmetric ain aquality aand aquantity afrom athe
aright aside aand athe aleft a
-palpate abilaterally
An ainequality aor aabsence aof apulse aon aone aside aof abody acan aindicate aa adisease
astate, asuch aas athrombus aor aaortic adissection.
Hyperthermia a- a(correct aanswer) a-an aabnormally aelevated abody atemperature,
agreater athan a104 adegrees aF a(40 aC). adue ato aa afailure aof athe athermoregulatory
amechanisms aof athe abody.
Hypothermia a- a(correct aanswer) a-a abody atemperature aless athan a95 adegrees aF a(35
aC)
considerations ain abody atemperature a- a(correct aanswer) a-Age a(newborn/older aadult)
Hormonal achanges
Exercise, aactivity, adehydration
Illness aand ainjury
recent afood aor afluid aintake aand asmoking
circadian arhythm, astress, aenvironmental aconditions
Autonomic anervous asystem a- a(correct aanswer) a-controls athe aheart arate.
Parasympathetic anervous asystem a- a(correct aanswer) a-lowers athe aheart arate.
CORRECT SOLUTIONS
Vital aSigns a- a(correct aanswer) a-Measurements aof athe abody's amost abasic afunctions,
aincluding: atemperature
pulse
respiration a
blood apressure
oxygen asaturation
pain alevel
Temperature aRange afor aadults a- a(correct aanswer) a-Oral. a96.8---100.4 aF a(36--38 aC)
Rectal ausually a0.9 aF a(0.5 aC) adegrees ahigher athan aoral aor atympanic, acloser ato athe
abody acore atemperature.
Axillary ausually a0.9F a(0.5C) alower athan aoral aand atympanic atemperatures.
Temporal anearly a1 adegree aF a(0.5 aC) ahigher athan aoral, aand a2 adegrees aF a(1
adegree aC) ahigher athan aaxillary.
aa aclient's ausual atemperature aserves aas aa abaseline afor acomparison.
Heat aproduction a- a(correct aanswer) a-results afrom aincreases ain abasal ametabolic
arate, amuscle aactivity, athyroxine aoutput, atestosterone, aand asympathetic astimulation,
awhich aincreases aheat aproduction.
Heat aloss a- a(correct aanswer) a-occurs afrom:
Conduction: atransfer aof ahear afrom athe abody adirectly ato aanother asurface a( aex:
aimmersion ain awater)
Convection: aDispersion aof ahear aby aair acurrents a(ex: awind ablowing aacross askin)
Evaporation: aDispersion aof aheat athrough awater avapor a(perspiration).
Radiation: aTransfer aof aheat afrom aone aobject ato aanother aobject awithout acontact
abetween athem a(heat alost afrom athe abody ato aa acold aroom)
Diaphoresis: aVisible aperspiration aon athe askin.
Physiologic aresponses a(temperature) a- a(correct aanswer) a-The aneurologic aand
acardiovascular asystems awork atogether ato aregulate abody atemperature. aDisease aor
atrauma aof athe ahypothalamus aor aspinal acord awith aalter atemperature acontrol.
Pulse a- a(correct aanswer) a-the ameasurement aof athe aheart arate aand arhythm.
Pulse arate a- a(correct aanswer) a-the anumber aof atimes aper aminute ayou afeel aor ahear
athe apulse.
, Pulse arhythm a- a(correct aanswer) a-The aregularity aof aimpulses. aA apremature, alate aor
amissed aheart abeat acan aresult ain aan airregular ainterval abetween aimpulses aand acan
aindicate aaltered aelectrical aactivity aof athe aheart. aA aregular apulse ais athe aexpected
afinding.
expected aheart arate arange a- a(correct aanswer) a-for aan aadult aclient a60 ato a100 abeats
aper aminute aat arest.
assess athe awave alike asensations aor aimpulses ayou afeel ain aa aperipheral aarterial
avessel aor aover athe aapex aof athe aheart aas aa agauge aof acardiovascular astatus.
strength a(amplitude aor apulse avolume) a- a(correct aanswer) a-Reflects athe avolume aof
ablood aejected aagainst athe aarterial awall awith aeach aheart acontraction aand athe
acondition aof athe aarterial avascular asystem. athe astrength aof athe aimpulse ashould abe
athe asame afrom abeat ato abeat.
Graded aon aa ascale afrom a0 ato a4:
0 a= aAbsent, aunable ato apalpate
1+ a= aDiminished, aweaker athan aexpected
2+ a= aBrisk, aexpected
3+ a= aIncreased, astrong
4+ a= aFull avolume, abounding
Equality aof apulse a- a(correct aanswer) a--symmetric ain aquality aand aquantity afrom athe
aright aside aand athe aleft a
-palpate abilaterally
An ainequality aor aabsence aof apulse aon aone aside aof abody acan aindicate aa adisease
astate, asuch aas athrombus aor aaortic adissection.
Hyperthermia a- a(correct aanswer) a-an aabnormally aelevated abody atemperature,
agreater athan a104 adegrees aF a(40 aC). adue ato aa afailure aof athe athermoregulatory
amechanisms aof athe abody.
Hypothermia a- a(correct aanswer) a-a abody atemperature aless athan a95 adegrees aF a(35
aC)
considerations ain abody atemperature a- a(correct aanswer) a-Age a(newborn/older aadult)
Hormonal achanges
Exercise, aactivity, adehydration
Illness aand ainjury
recent afood aor afluid aintake aand asmoking
circadian arhythm, astress, aenvironmental aconditions
Autonomic anervous asystem a- a(correct aanswer) a-controls athe aheart arate.
Parasympathetic anervous asystem a- a(correct aanswer) a-lowers athe aheart arate.
