ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
A 45-year-old woman presents with sudden onset of severe, unilateral lower abdominal pain. She also reports nausea and vomiting. On examination, she has tenderness to palpation in the right lower quadrant. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Ovarian cyst rupture. The sudden onset of severe, unilateral lower abdominal pain along with nausea and vomiting suggests a possible rupture of an ovarian cyst. The tenderness in the right lower quadrant can be due to the location of the affected ovary. Ovarian cyst rupture can mimic symptoms of appendicitis (choice A), but the absence of fever and rebound tenderness makes appendicitis less likely. Pelvic inflammatory disease (choice C) typically presents with bilateral lower abdominal pain and a history of vaginal discharge. Ectopic pregnancy (choice D) may present with similar symptoms, but the absence of vaginal bleeding and a positive pregnancy test makes it less likely in this case.
Question 2 of 5
The nurse is assessing a patient's cranial nerve function and notes that the patient has absent corneal reflex on one side. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Unilateral facial nerve paralysis. The corneal reflex is mediated by the trigeminal nerve (cranial nerve V) afferent limb and facial nerve (cranial nerve VII) efferent limb. Absent corneal reflex on one side indicates a dysfunction in the facial nerve, which controls the blinking reflex in response to corneal stimulation. Trigeminal nerve dysfunction (choice B) would present with sensory deficits, not specifically affecting the corneal reflex. Upper motor neuron lesion (choice C) would typically present with bilateral findings, and lower motor neuron lesion (choice D) would affect the facial muscles directly, not the corneal reflex.
Question 3 of 5
The nurse is performing a cardiovascular assessment and hears a murmur during diastole. What condition is most likely associated with this finding?
Correct Answer: B
Rationale: Step-by-step rationale for why choice B, Mitral stenosis, is correct: 1. Mitral stenosis causes narrowing of the mitral valve, leading to turbulent blood flow during diastole, resulting in a diastolic murmur. 2. Aortic regurgitation (choice A) involves regurgitation of blood back into the left ventricle during diastole, causing a systolic murmur. 3. Tricuspid regurgitation (choice C) and pulmonary hypertension (choice D) also present with systolic murmurs, not diastolic as in the scenario described. In summary, the diastolic murmur heard during the cardiovascular assessment is most likely associated with mitral stenosis due to the narrowed mitral valve causing turbulent blood flow during diastole, differentiating it from the other choices.
Question 4 of 5
This condition may produce a subnormal temperature:
Correct Answer: C
Rationale: Hypothyroidism, is correct because an underactive thyroid reduces metabolism, lowering heat production and thus body temperature (e.g., below 97°F). Cerebral palsy, affects movement, not thermoregulation directly. Infection, typically raises temperature (fever). Fever, by definition increases temperature. Hypothyroidism slows cellular activity, impairing the bodys ability to maintain normal temperature, often causing cold intolerance. Clinical evidence links it to subnormal readings, unlike the other options, which either elevate temperature or have no direct effect. Thus, C is the accurate choice based on endocrine physiology.
Question 5 of 5
A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
Correct Answer: A
Rationale: A blood pressure of 130/90 mmHg is mildly elevated (prehypertension or Stage 1 hypertension). Follow-up measurements are recommended to confirm if its persistent, as a single reading isnt diagnostic. Immediate treatment is premature without trends. Assuming anxiety dismisses the need for monitoring, which is risky. Dietary changes may help long-term but arent the first step. Choice A aligns with guidelines (e.g., AHA) for tracking blood pressure over time to establish a pattern, ensuring proper management.