ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A 65-year-old man presents with chest pain and dyspnea. He has a history of coronary artery disease and diabetes mellitus. His ECG shows ST-segment elevation in leads II, III, and aVF. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct diagnosis is A: Myocardial infarction. The ST-segment elevation in leads II, III, and aVF on the ECG indicates an inferior wall myocardial infarction. This presentation, along with the patient's age, history of coronary artery disease, and diabetes mellitus, strongly suggests myocardial infarction. Angina (B) typically presents with transient chest pain that is relieved with rest or medication. Pulmonary embolism (C) presents with sudden-onset dyspnea and chest pain, often accompanied by tachycardia. Aortic dissection (D) commonly presents with severe tearing chest pain radiating to the back, not ST-segment elevation on ECG.
Question 2 of 5
The nurse is auscultating the lungs and hears a pleural friction rub. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Pleuritis. A pleural friction rub is caused by the inflammation of the pleural surfaces rubbing against each other during breathing. Pleuritis is the most likely cause as it directly involves inflammation of the pleura. Pneumonia (choice A) typically presents with crackles or decreased breath sounds. Pulmonary embolism (choice C) may present with pleuritic chest pain but not a friction rub. Chronic obstructive pulmonary disease (COPD) (choice D) is characterized by wheezing and decreased breath sounds, not a friction rub. Pleuritis is the only choice directly related to the inflammation of the pleura, leading to a pleural friction rub.
Question 3 of 5
During a respiratory assessment, the nurse notes that the patient is breathing with the use of accessory muscles. What does this finding suggest?
Correct Answer: B
Rationale: The correct answer is B, respiratory distress. When a patient is using accessory muscles to breathe, it indicates increased effort to maintain adequate ventilation, a hallmark of respiratory distress. This can be due to various conditions such as asthma, pneumonia, or acute respiratory distress syndrome. Accessory muscle use is a compensatory mechanism to help increase airflow in the presence of respiratory compromise. Choices A, C, and D are incorrect because the use of accessory muscles is not indicative of a normal breathing pattern, pulmonary embolism, or COPD specifically. It is important to recognize and address respiratory distress promptly to prevent further complications.
Question 4 of 5
During a cardiovascular assessment, the nurse notes that the patient has a rapid, irregular pulse. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Atrial fibrillation. A rapid, irregular pulse is a classic hallmark of atrial fibrillation, which is a common arrhythmia characterized by disorganized electrical activity in the atria. This leads to an irregular and often rapid ventricular response. Sinus arrhythmia (B) is a normal variation in heart rate associated with breathing and is typically regular. Ventricular tachycardia (C) is a life-threatening arrhythmia with a regular, fast heartbeat originating in the ventricles. Bradycardia (D) is a slow heart rate, which is the opposite of what is described in the question.
Question 5 of 5
Upon admission, the most appropriate person to check on a patients vital signs would be:
Correct Answer: A
Rationale: RN (Registered Nurse), is correct because upon admission, a comprehensive assessment, including vital signs, is typically performed by an RN due to their advanced training and scope of practice. RNs interpret data, identify abnormalities, and develop care plans, making them the most appropriate initial evaluator. LPN (Licensed Practical Nurse), assists with care but often works under RN supervision with a narrower scope. PCT (Patient Care Technician), and CNA (Certified Nursing Assistant), perform basic tasks like taking vital signs but lack the RNs authority to assess and act on findings independently upon admission. Hospital protocols prioritize RNs for initial assessments to ensure accuracy and timely intervention, especially in critical cases. Thus, A is the best choice, reflecting professional standards and patient safety priorities.