ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
A 60-year-old woman presents with pain in her knees and hips that is worse with activity and improves with rest. On examination, she has decreased range of motion and crepitus in the affected joints. Which of the following is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Osteoarthritis. In a 60-year-old woman with joint pain worsened with activity, improved with rest, decreased range of motion, and crepitus, osteoarthritis is the most likely diagnosis due to its characteristic presentation in weight-bearing joints. Osteoarthritis is a degenerative joint disease characterized by cartilage breakdown, leading to pain and stiffness. Rheumatoid arthritis (B) typically presents with symmetric joint involvement, morning stiffness, and systemic symptoms. Gout (C) manifests as sudden onset of severe joint pain, redness, and swelling, commonly affecting the big toe. Psoriatic arthritis (D) is associated with skin psoriasis and may involve asymmetric joint inflammation.
Question 2 of 5
During a neurological assessment, the nurse observes that the patient has difficulty walking on their toes. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar ataxia. Difficulty walking on toes is a sign of cerebellar dysfunction, affecting coordination and balance. The cerebellum plays a crucial role in coordinating voluntary movements, including maintaining balance and posture. In cerebellar ataxia, there is a lack of coordination in muscle movements, leading to difficulties in performing fine motor tasks like walking on toes. Peripheral neuropathy (B) primarily affects sensory and motor nerves in the limbs, causing tingling, numbness, and weakness, not specifically difficulty in walking on toes. Parkinson's disease (C) is characterized by tremors, rigidity, and bradykinesia but typically does not present with difficulty walking on toes. Stroke (D) can cause motor deficits but typically does not manifest as isolated difficulty walking on toes.
Question 3 of 5
A 30-year-old man presents with a complaint of frequent headaches. He describes them as severe and one-sided, lasting 30 minutes to an hour. He reports that the headaches are often associated with eye watering and nasal congestion. What is the most likely diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Cluster headache. This is because the patient's symptoms of severe one-sided headaches lasting 30 minutes to an hour, associated with eye watering and nasal congestion, are classic features of cluster headaches. These headaches are often described as excruciating and occur in clusters or cycles. Other choices can be ruled out based on the specific characteristics of the headaches described. Migraines typically last longer, tension-type headaches are usually bilateral and milder in intensity, and sinus headaches are often associated with sinus infections which the patient does not present with.
Question 4 of 5
The nurse is performing a cardiovascular assessment and auscultates a grade 3/6 murmur at the left lower sternal border. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Document the murmur and report it to the physician. A grade 3/6 murmur is moderate in intensity and may indicate a significant underlying heart condition. By documenting and reporting it to the physician promptly, the nurse ensures timely evaluation and appropriate management. Reassessing the murmur in 30 minutes (choice A) may delay necessary intervention. Performing a complete physical examination to rule out other cardiac abnormalities (choice C) is important but may not be immediately necessary for addressing the murmur. Initiating cardiac monitoring immediately (choice D) is not the priority in this scenario; informing the physician for further evaluation is more crucial.
Question 5 of 5
The nurse is assessing a patient's abdomen and notes that the patient has a firm, non-tender mass. What is the next step in the assessment?
Correct Answer: D
Rationale: The correct answer is D: Refer the patient for imaging. When a nurse encounters a firm, non-tender mass in the abdomen, it is important to proceed with imaging to determine the nature of the mass. Imaging studies such as ultrasound, CT scan, or MRI can provide valuable information about the size, location, and characteristics of the mass. This step is crucial in identifying the potential underlying causes of the mass, such as tumors, cysts, or other abnormalities. Option A is incorrect because percussion is not typically used to assess for fluid in a mass. Option B is incorrect as palpation may not be safe if the mass is suspected to be malignant. Option C is incorrect as auscultation for bowel sounds may not provide relevant information about the mass. The best course of action is to refer the patient for imaging to further evaluate the mass accurately.