ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A 40-year-old woman presents with a complaint of frequent urination and increased thirst. She reports that these symptoms have been present for several weeks. She has a family history of diabetes mellitus. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for the 40-year-old woman presenting with frequent urination, increased thirst, and a family history of diabetes mellitus is diabetes mellitus (Choice A). 1. Symptoms of frequent urination and increased thirst are classic signs of diabetes mellitus. 2. Family history of diabetes increases the likelihood of developing the condition. 3. Other choices are less likely: - Urinary tract infection (Choice B) typically presents with symptoms such as pain or burning sensation during urination, fever, and cloudy urine. - Hypercalcemia (Choice C) is characterized by elevated levels of calcium in the blood and is not directly related to the symptoms described. - Cystitis (Choice D) is inflammation of the bladder and usually presents with symptoms like pain or discomfort in the pelvic area, frequent urination, and urgency to urinate. In summary, based on the patient's symptoms and family history, diabetes mellitus is the most likely diagnosis, while the other choices
Question 2 of 5
During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Palpation with deep pressure on the right upper quadrant. This technique is appropriate because the liver is located in the right upper quadrant of the abdomen, and palpation with deep pressure allows the nurse to feel for any enlargement or abnormalities. Percussion (Choice A) is used to identify organ borders, not necessarily to assess for enlargement. Auscultation for liver bruits (Choice C) is not typically done during a routine abdominal examination for liver enlargement. Inspection for visible pulsations (Choice D) is more indicative of an abdominal aortic aneurysm, not liver enlargement.
Question 3 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.
Question 4 of 5
The most appropriate position in obtaining a rectal temperature for an adult would be:
Correct Answer: C
Rationale: Sims, is correct because the Sims position (left lateral with upper leg flexed) provides optimal access to the rectum for temperature measurement in adults. It ensures patient comfort and safety while allowing the nurse to insert the probe accurately. Supine (lying flat on back), is impractical for rectal access. Fowlers (semi-sitting), is used for respiratory ease, not rectal procedures. Lateral (side-lying), is close but less specific than Sims, which includes leg positioning for better exposure. Rectal temperature, a core measurement, requires proper positioning to avoid discomfort or injury, and Sims is standard in clinical practice for its anatomical alignment, making C the most appropriate choice.
Question 5 of 5
A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments?
Correct Answer: A
Rationale: Pain stimulates the sympathetic nervous system, often increasing pulse rate as the body responds to stress, a common finding in acute abdominal pain. A decrease in body temperature isnt typical, as pain may elevate temperature if inflammation is present. A decrease in blood pressure could occur in shock but isnt a primary pain response; pain often increases blood pressure initially. An increase in respiratory depth (D replaced with E) and rate (E) may occur, but the correct answer focuses on A. Pain typically accelerates pulse and respiratory rate while potentially decreasing depth, not increasing it. Choice A is correct as it consistently aligns with physiological responses to severe pain, supported by clinical observations of tachycardia in painful conditions like appendicitis or perforation.