ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A 55-year-old woman presents with a complaint of a persistent headache, blurred vision, and nausea. Her blood pressure is 170/110 mm Hg. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Hypertensive emergency. The patient's symptoms of persistent headache, blurred vision, and high blood pressure indicate a hypertensive emergency, a severe increase in blood pressure requiring immediate medical attention to prevent organ damage. Primary hypertension (A) is chronic high blood pressure without acute symptoms. Cluster headache (C) is characterized by severe, unilateral head pain with associated symptoms, not necessarily elevated blood pressure. Migraine (D) is a recurrent headache disorder with specific features, not typically associated with such high blood pressure levels.
Question 2 of 5
During a cardiovascular assessment, the nurse auscultates a soft, blowing sound over the left upper sternal border. What does this finding suggest?
Correct Answer: B
Rationale: The correct answer is B: Heart murmur. The soft, blowing sound heard over the left upper sternal border indicates the presence of turbulent blood flow within the heart, which is characteristic of a heart murmur. This finding suggests abnormal flow patterns, such as valve dysfunction or structural abnormalities. Heart failure (C) typically presents with other symptoms like edema and shortness of breath. Normal heart sounds (A) do not include blowing sounds. Aortic stenosis (D) would present with a harsh systolic ejection murmur, not a soft blowing sound.
Question 3 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a limited range of motion in the shoulder. What is the next step in the assessment?
Correct Answer: A
Rationale: The correct next step in assessing a limited range of motion in the shoulder is to palpate the shoulder for tenderness. This is important to identify any underlying causes of the limited range of motion, such as inflammation or injury. Palpation helps the nurse determine if there is any pain or tenderness in the shoulder joint, which can provide valuable information for further assessment and treatment planning. Performing passive range of motion (choice B) would be inappropriate without first assessing for tenderness. Auscultation for crepitus (choice C) is not typically indicated for assessing limited range of motion in the shoulder. Measuring the angle of motion (choice D) is not as relevant in this context as assessing for tenderness.
Question 4 of 5
The nurse is assessing a patient for signs of acute respiratory distress syndrome (ARDS). What finding is most consistent with this condition?
Correct Answer: A
Rationale: The correct answer is A: Fine crackles on auscultation. In ARDS, the alveoli become filled with fluid, leading to the crackling sound. Fine crackles indicate the presence of fluid in the small airways, which is a hallmark of ARDS. Wheezing (B) is more commonly associated with asthma or chronic obstructive pulmonary disease. Decreased tactile fremitus (C) may suggest pleural effusion or pneumothorax, not ARDS. Dullness on percussion (D) is seen in conditions like pneumonia or pleural effusion, not specifically ARDS. Therefore, the presence of fine crackles on auscultation is the most consistent finding with ARDS.
Question 5 of 5
During a respiratory assessment, the nurse notes that the patient has a prolonged inspiratory phase. What condition is most likely associated with this finding?
Correct Answer: D
Rationale: The correct answer is D: Upper airway obstruction. A prolonged inspiratory phase suggests difficulty with air intake, which is commonly seen in upper airway obstructions such as foreign body aspiration, croup, or epiglottitis. Asthma (A) typically presents with prolonged expiratory phase, COPD (B) with decreased expiratory phase, and pulmonary fibrosis (C) with decreased lung compliance and restrictive pattern, not affecting inspiratory phase.