ATI RN
Assess Vital Signs Questions
Question 1 of 5
A 50-year-old man presents with a complaint of chronic cough. He has a 30-year history of smoking. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for a 50-year-old man with chronic cough and a history of smoking is Chronic Obstructive Pulmonary Disease (COPD). 1) History of smoking is a major risk factor for COPD. 2) Chronic cough is a common symptom of COPD due to airway inflammation and mucus production. 3) COPD typically develops over years of smoking. Other choices are less likely: B) Pneumonia usually presents with acute symptoms; C) Lung cancer may present with cough but usually in later stages; D) Tuberculosis is less common in a chronic smoker without other risk factors. Therefore, the correct answer is A.
Question 2 of 5
The nurse is assessing a patient's cranial nerve function and asks the patient to shrug both shoulders. Which cranial nerve is being tested?
Correct Answer: D
Rationale: The correct answer is D, Cranial nerve XI (spinal accessory nerve). This nerve controls the trapezius and sternocleidomastoid muscles, responsible for shoulder shrugging. Cranial nerve V (A) controls facial sensation and jaw movement. Cranial nerve VII (B) controls facial expression. Cranial nerve IX (C) controls swallowing and taste sensation. By process of elimination, D is the only nerve related to shoulder shrugging.
Question 3 of 5
During a cardiovascular assessment, the nurse palpates the carotid pulse. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct action after palpating the carotid pulse is to auscultate for bruits. Bruits are abnormal sounds caused by turbulent blood flow, which may indicate vascular disease. Auscultating for bruits specifically at the carotid arteries is important in assessing for potential arterial blockages that can lead to serious complications like stroke. Palpating the femoral pulse (Choice A) is not the next immediate step in a cardiovascular assessment after assessing the carotid pulse. Comparing the pulse rate with the apical pulse (Choice C) is important but not the immediate action required after palpating the carotid pulse. Palpating the radial pulse (Choice D) is also an important part of the assessment, but in this scenario, auscultating for bruits takes precedence for further evaluation.
Question 4 of 5
The nurse is assessing a patient's abdomen and notes that the patient has ascites. What physical examination technique should the nurse use next?
Correct Answer: A
Rationale: The correct answer is A: Percussion for shifting dullness. Ascites is the accumulation of fluid in the peritoneal cavity leading to abdominal distension. By percussing the abdomen for shifting dullness, the nurse can identify fluid waves within the abdomen, confirming the presence of ascites. This technique helps differentiate ascites from other causes of abdominal distension. Auscultation for bowel sounds (B) is not directly related to assessing ascites. Palpation for tenderness (C) may be performed after confirming ascites to assess for underlying causes. Inspection for visible distension (D) can provide initial clues, but percussion for shifting dullness is needed for a definitive diagnosis of ascites.
Question 5 of 5
During a cardiovascular assessment, the nurse auscultates a split S2. What does this finding most likely indicate?
Correct Answer: A
Rationale: The split S2 sound is typically heard during inspiration and is considered a normal finding. It occurs due to a slight delay in the closure of the aortic valve compared to the pulmonic valve. This physiological delay results in the splitting of the S2 heart sound. Aortic stenosis (B), heart failure (C), and pulmonary embolism (D) are associated with different abnormal cardiovascular conditions that would present with other characteristic auscultatory findings, such as murmurs, gallops, or wheezing, respectively.