ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago but 'he didn't have a scratch afterward.' She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
Correct Answer: B
Rationale: The correct answer is B: Transfer to radiology for a CT scan. This is the first collaborative intervention to implement because the patient's history of falling down the stairs a month ago with subsequent absence of visible injuries raises concern for possible head trauma. The acute lethargy, confusion, and incontinence could be indicative of a traumatic brain injury or intracranial bleeding. A CT scan is crucial to assess for any structural brain abnormalities that may require immediate intervention. Choice A: Placing on the hospital alcohol withdrawal protocol is not the first priority as the patient's symptoms are more suggestive of a potential head injury rather than alcohol withdrawal. Choice C: Inserting a retention catheter to straight drainage may be necessary for managing incontinence, but it does not address the primary concern of assessing for potential head trauma. Choice D: Giving phenytoin (Dilantin) 100 mg PO is not appropriate as the patient's symptoms are not necessarily indicative of seizures and administering ant
Question 2 of 5
During a respiratory assessment, the nurse observes that the patient's chest moves asymmetrically during inspiration. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. During a pneumothorax, air enters the pleural space, causing lung collapse and leading to asymmetric chest movement during inspiration. This occurs because the affected lung cannot fully expand. Other choices are incorrect because pleural effusion and asthma exacerbation usually do not cause asymmetric chest movement, and COPD typically results in symmetric chest movement due to chronic air trapping.
Question 3 of 5
The nurse is assessing the abdomen of a patient and notes visible peristalsis. What does this finding most likely indicate?
Correct Answer: B
Rationale: Visible peristalsis indicates increased activity of the intestines in attempting to move contents along. This is commonly seen in intestinal obstruction, where the intestines are trying to push against the blockage. This finding is not associated with normal digestion, dehydration, or abdominal distension, making option B the correct answer.
Question 4 of 5
During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?
Correct Answer: A
Rationale: To assess a pulse deficit, the nurse should first measure the apical pulse (using a stethoscope at the apex of the heart) and the radial pulse (at the wrist) simultaneously for a full minute. This is because the apical pulse represents the heart's contraction and the radial pulse represents the pulse felt at the periphery. The difference between the two rates indicates a pulse deficit, which suggests that not all heartbeats are reaching the periphery. This method allows for a direct comparison between the heart rate and the peripheral pulse rate. The other choices are incorrect because measuring the pulse strength in both radial arteries (B) does not assess for a pulse deficit, auscultating for murmurs (C) is not directly related to assessing a pulse deficit, and palpating carotid and femoral pulses simultaneously (D) does not provide a comparison between the heart rate and peripheral pulse rate.
Question 5 of 5
The following information is recorded in the health history: 'The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area.' Which of these categories does it belong to?
Correct Answer: B
Rationale: The correct answer is B: Present illness. The present illness section of a health history includes detailed information about the current health problem, such as the duration, characteristics, severity, associated symptoms, and location of the symptoms. In this case, the information provided about the patient's abdominal pain, including its duration, intensity, pattern, associated symptoms, and location, falls under the present illness category. This information is essential for healthcare providers to understand the current health issue and make an accurate diagnosis and treatment plan. Choice A (Chief complaint) typically refers to the main reason for the patient seeking medical attention, which is usually a concise statement in the patient's own words. The information provided is more detailed than a typical chief complaint. Choice C (Personal and social history) includes information about the patient's lifestyle, habits, social support, and past medical history. The information provided is focused on the current health issue rather than personal or social background. Choice D (Review of systems) involves a systematic inquiry