ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
Correct Answer: C
Rationale: The correct answer is C: Tuberculosis. The key clues in the patient's history are rust-colored sputum, low-grade fevers, and night sweats, which are classic symptoms of tuberculosis. Rust-colored sputum is indicative of blood in the sputum, a common finding in pulmonary tuberculosis. Low-grade fevers and night sweats are also typical symptoms of tuberculosis due to the body's immune response to the infection. Bronchitis (A) typically presents with cough and mucus production without the specific symptoms described. Pneumonia (B) can present with productive cough and fever, but rust-colored sputum and night sweats are less common. Pulmonary edema (D) usually presents with symptoms like shortness of breath and pink frothy sputum, not rust-colored sputum and night sweats.
Question 2 of 5
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: Elevated pressure related to heart failure. The finding of jugular venous pulsations 5 cm above the sternal angle when the head of the bed is elevated 45 degrees is indicative of elevated central venous pressure, which is commonly seen in patients with heart failure. This is known as the hepatojugular reflux test, where pressure is transmitted back to the jugular veins due to increased right atrial pressure in heart failure. This finding suggests impaired cardiac function leading to fluid overload and congestion in the venous system. Choices A, B, and C are incorrect because they do not explain the specific pathophysiological mechanism associated with the patient's presentation.
Question 3 of 5
When assessing a child's lung sounds, the nurse hears loud, low-pitched tones. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider this finding normal for a child. Loud, low-pitched lung sounds in children are often attributed to their thin chest walls and clear airways. Step 1: Understand that children's lung sounds can be louder and lower-pitched compared to adults due to their anatomy. Step 2: Recognize that this finding is typically normal in children and does not require further investigation. Summary: Options B, C, and D are incorrect as they are unnecessary and may lead to unnecessary procedures or testing when the finding is normal in children.
Question 4 of 5
Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely?
Correct Answer: D
Rationale: The correct answer is D because the absence of symmetry of the inguinal areas with straining indicates a possible hernia. When Francis strains, if there is asymmetry in the inguinal areas, it suggests a weakness in the abdominal wall allowing for a hernia to protrude. This is a key sign of a hernia. A: Absence of pain with straining is not indicative of a hernia. Pain is often present in hernias. B: Absence of bowel sounds in the scrotum is not a typical sign of a hernia. Bowel sounds are usually heard in the abdomen. C: Absence of a varicocele refers to enlarged veins in the scrotum, which is unrelated to a hernia.
Question 5 of 5
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse.
Correct Answer: C
Rationale: The correct answer is C: Bounding. In hyperthyroidism, there is an excess of thyroid hormones which can lead to an increased heart rate and force of contraction. Bounding pulse refers to a strong and forceful pulse, which is expected in hyperthyroidism due to the increased cardiac output. Normal pulse (A) would not be expected as the heart rate is usually elevated in hyperthyroidism. Absent pulse (B) is not appropriate as hyperthyroidism typically leads to an increased pulse. Weak, thready pulse (D) is not expected as the increased cardiac output in hyperthyroidism usually results in a strong pulse.