ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A 65-year-old man presents with shortness of breath and a dry cough. He has a history of smoking and frequent sinus infections. Chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct diagnosis is A: Sarcoidosis. In this case, the key features are bilateral hilar lymphadenopathy, shortness of breath, dry cough, smoking history, and frequent sinus infections. Sarcoidosis commonly presents with these symptoms and radiographic findings. Hilar lymphadenopathy is a classic feature of sarcoidosis due to granuloma formation. Lung cancer (B) is less likely given the presentation and the absence of lung mass on imaging. Pneumonia (C) typically presents with consolidations on chest X-ray, which is not seen in this case. Chronic obstructive pulmonary disease (D) is characterized by airflow limitation and does not typically present with hilar lymphadenopathy.
Question 2 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Babinski sign. What does this finding indicate?
Correct Answer: B
Rationale: The positive Babinski sign indicates upper motor neuron dysfunction. When the sole of the foot is stroked, the big toe extends upward instead of curling down. This suggests damage to the corticospinal tract, characteristic of upper motor neuron lesions. Choices A, C, and D are incorrect because a positive Babinski sign is not a normal finding in adults, not related to peripheral neuropathy, and not indicative of cerebellar dysfunction.
Question 3 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 4 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 5 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.