ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A 60-year-old woman presents with a complaint of painful and swollen joints in her hands, especially in the morning. She also reports stiffness that lasts for over an hour. What is the most likely diagnosis?
Correct Answer: B
Rationale: The most likely diagnosis is Rheumatoid arthritis (RA). RA commonly presents with painful, swollen joints in the hands, particularly in the morning, along with prolonged stiffness. The autoimmune nature of RA causes inflammation, leading to these symptoms. Osteoarthritis (A) typically presents with joint pain that worsens with activity but improves with rest, not specifically in the morning. Gout (C) usually involves sudden, severe pain in a single joint, not multiple joints in the morning. Systemic lupus erythematosus (D) is characterized by a variety of symptoms beyond joint pain, such as skin rashes and fatigue, making it less likely in this case.
Question 2 of 5
The nurse is assessing a patient's abdomen and detects a mass. What is the next step in the assessment?
Correct Answer: C
Rationale: The correct next step in assessing a detected abdominal mass is to palpate it for size and consistency. Palpation helps determine the characteristics of the mass, such as its shape, size, texture, and tenderness. This step provides crucial information for further evaluation and diagnosis. Auscultation for bowel sounds would not provide direct information about the mass. Percussion for tenderness may be uncomfortable and should be done after palpation. Referring the patient for imaging should come after a thorough physical examination and initial assessment of the mass.
Question 3 of 5
The nurse is performing an abdominal examination and detects a bruit over the aorta. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The presence of a bruit over the aorta during an abdominal examination is most likely associated with an Aortic Aneurysm. Aneurysms can cause turbulent blood flow resulting in a bruit. Aortic aneurysm is a common location for this finding due to the dilation of the aorta. Renal artery stenosis, pneumonia, and pancreatitis are not typically associated with a bruit over the aorta, making them incorrect choices.
Question 4 of 5
The nurse is assessing a patient's lungs and hears a harsh, grating sound during both inspiration and expiration. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Pleural friction rub. This sound occurs due to the rubbing together of inflamed pleural surfaces during both inspiration and expiration. It is typically heard in conditions such as pleurisy or pneumonia. Rhonchi (B) are low-pitched rattling sounds typically heard during expiration, wheezing (C) is a high-pitched musical sound heard during expiration, and pneumothorax (D) presents with decreased or absent breath sounds on the affected side, not a friction rub.
Question 5 of 5
Which of the following values for vital signs would the nurse address first?
Correct Answer: B
Rationale: Oxygen saturation of 89%, is correct because its the most urgent. Normal oxygen saturation is 95-100%; 89% indicates hypoxemia, risking tissue damage and requiring immediate intervention (e.g., oxygen therapy). Temperature of 99°F, is slightly elevated but not critical. Respirations of 28, is high (normal 12-20), but less acute without context like distress. BP 160/89, suggests stage 1 hypertension, concerning but not immediately life-threatening. Nurses prioritize airway, breathing, and circulation (ABCs); low oxygen saturation directly impairs oxygenation, making B the top priority for swift action to prevent complications like organ failure.