ATI RN
Vital Signs Assessment Questions
Question 1 of 5
A 25-year-old woman presents with a complaint of dizziness and fainting. On examination, her blood pressure is 90/60 mm Hg. Which of the following is the most likely cause of her symptoms?
Correct Answer: A
Rationale: The correct answer is A: Postural hypotension. This condition typically presents with symptoms of dizziness and fainting upon standing due to a drop in blood pressure. In this case, the blood pressure of 90/60 mm Hg indicates hypotension, which is exacerbated by changes in position. Acute myocardial infarction (B) presents with chest pain and ECG changes, not dizziness. Arrhythmia (C) can cause palpitations but not necessarily dizziness. Hyperthyroidism (D) can cause palpitations and weight loss but not typically dizziness and fainting.
Question 2 of 5
The nurse is performing a respiratory assessment and notes that the patient has crackles in the lower lung fields. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary edema. Crackles in the lower lung fields are indicative of fluid accumulation in the alveoli, which is characteristic of pulmonary edema. This condition is commonly seen in heart failure when the heart is unable to effectively pump blood, leading to fluid backup in the lungs. Pleural effusion (A) is the accumulation of fluid in the pleural space, not in the alveoli. Pneumonia (B) typically presents with other symptoms like fever and productive cough. COPD (D) is characterized by airflow limitation and is not directly associated with crackles due to fluid accumulation.
Question 3 of 5
The nurse is assessing a patient for signs of dehydration. Which finding is most indicative of dehydration?
Correct Answer: B
Rationale: The correct answer is B, dry mouth and tongue. Dehydration often leads to decreased saliva production, resulting in a dry mouth and tongue. This is a more specific and direct sign of dehydration compared to the other choices. Increased skin turgor (choice A) is a sign of dehydration but can be influenced by other factors. Bounding pulse (choice C) is a sign of fluid overload, not dehydration. Moist mucous membranes (choice D) are a normal finding and not indicative of dehydration. Overall, dry mouth and tongue are the most specific and reliable indicators of dehydration in a patient assessment.
Question 4 of 5
The nurse is performing a cardiovascular assessment and palpates the apical pulse. What is the normal location of the apical pulse?
Correct Answer: B
Rationale: The correct answer is B: Fifth intercostal space, midclavicular line. This is where the apex of the heart is located, making it the normal position to palpate the apical pulse. Palpating at the second intercostal space (A) would be locating the aortic area, not the apical pulse. The fourth intercostal space (C) is where the tricuspid valve is auscultated, not where the apical pulse is palpated. The sixth intercostal space (D) is closer to the location of the mitral valve, but it is not the precise location of the apical pulse.
Question 5 of 5
The nurse is performing a neurological assessment and observes that the patient has difficulty with rapid alternating movements. What condition does this finding suggest?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar dysfunction. Difficulty with rapid alternating movements is a classic sign of cerebellar dysfunction due to the cerebellum's role in coordinating smooth and coordinated movements. This finding suggests impairment in the cerebellum's ability to control motor function, leading to problems with coordination and rapid movements. Peripheral neuropathy (B) primarily affects sensory and motor functions in the peripheral nervous system, not specifically rapid alternating movements. Motor weakness (C) refers to a generalized decrease in muscle strength and is not specific to rapid alternating movements. An upper motor neuron lesion (D) typically presents with spasticity and weakness but does not specifically affect rapid alternating movements as seen in cerebellar dysfunction.