ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A 40-year-old woman presents with complaints of fatigue and muscle weakness. On examination, she has ptosis and weakness of the proximal muscles of the upper limbs. What is the most likely diagnosis?
Correct Answer: B
Rationale: The most likely diagnosis for a 40-year-old woman presenting with ptosis, fatigue, and weakness of proximal upper limb muscles is myasthenia gravis (B). Myasthenia gravis is an autoimmune disorder characterized by muscle weakness that worsens with activity and improves with rest. Ptosis and proximal muscle weakness are classic features of myasthenia gravis due to antibodies targeting the acetylcholine receptors at the neuromuscular junction, leading to impaired muscle contraction. Multiple sclerosis (A) presents with neurological symptoms such as sensory deficits, vision changes, and coordination issues. Guillain-Barré syndrome (C) manifests as ascending muscle weakness and can have autonomic involvement. Lambert-Eaton syndrome (D) is characterized by muscle weakness that improves with activity, the opposite of myasthenia gravis.
Question 2 of 5
During an abdominal examination, the nurse hears high-pitched, tinkling bowel sounds. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The high-pitched, tinkling bowel sounds indicate hyperperistalsis in response to bowel obstruction, leading to air and fluid passing through the narrowed area. This finding is consistent with option B, gastrointestinal obstruction. Normal peristalsis (option A) would present with regular, rhythmic bowel sounds. Gastroesophageal reflux disease (option C) is unrelated to bowel sounds and presents with heartburn and regurgitation. Diverticulitis (option D) typically presents with localized tenderness and pain in the lower left abdomen, not high-pitched bowel sounds. Therefore, the correct answer is B due to the characteristic bowel sound associated with gastrointestinal obstruction.
Question 3 of 5
The nurse is assessing a patient's cranial nerve function and asks the patient to stick out their tongue. Which cranial nerve is being tested?
Correct Answer: D
Rationale: The correct answer is D: Cranial nerve XII (hypoglossal nerve). When the nurse asks the patient to stick out their tongue, they are testing the function of the hypoglossal nerve, which innervates the muscles responsible for tongue movement. Cranial nerve X (vagus nerve) is responsible for various functions such as swallowing and speech. Cranial nerve VII (facial nerve) controls facial expressions. Cranial nerve IX (glossopharyngeal nerve) is involved in taste sensation and swallowing. Therefore, the hypoglossal nerve is specifically responsible for tongue movement, making it the correct answer in this context.
Question 4 of 5
The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger and then touch the nurse's finger. Which aspect of neurological function is being tested?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar function and coordination. This task, known as the finger-to-nose test, assesses the coordination and accuracy of movements controlled by the cerebellum. When the patient is asked to touch their nose and then the nurse's finger, any inaccuracies or tremors in movement indicate cerebellar dysfunction. Choice B is incorrect as cranial nerve function is not specifically tested in this task. Choice C is incorrect as proprioception, the sense of body position and movement, is not the primary focus of this test. Choice D is incorrect as memory is not being directly assessed in this task.
Question 5 of 5
The nurse is performing an abdominal assessment and notes that the patient has a distended abdomen with tympany on percussion. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Gastrointestinal obstruction. A distended abdomen with tympany on percussion is indicative of trapped air in the intestines, commonly seen in gastrointestinal obstruction. This occurs when there is a blockage in the intestines, causing gas to accumulate and result in the distension. Ascites (B) is the accumulation of fluid in the abdominal cavity, which would present with dullness on percussion, not tympany. Pancreatitis (C) and Hepatomegaly (D) typically do not present with tympany on percussion and are not likely to cause a distended abdomen with this specific finding.