ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
A client admitted to the hospital with a neurological problem requires magnetic resonance imaging. The nurse understands that the client may be ineligible for this diagnostic procedure based on the client's history of:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Prosthetic valve replacement. The reason for this is that individuals with certain metallic implants or devices, such as prosthetic heart valves, pacemakers, or other metallic objects in their bodies, may not be eligible for magnetic resonance imaging (MRI) due to the risk of interference with the magnetic field of the machine. Option A) Hypertension, Option B) Heart failure, and Option D) Chronic obstructive pulmonary disorder do not typically preclude a patient from undergoing an MRI procedure. Hypertension, heart failure, and COPD are common health conditions that are not contraindications for MRI. Educationally, this question highlights the importance of understanding contraindications to specific diagnostic procedures based on a patient's medical history. Nurses need to be aware of these contraindications to ensure patient safety and the accuracy of diagnostic tests. This knowledge helps in providing optimal care and preventing potential risks or complications for patients undergoing medical procedures.
Question 2 of 5
A physical therapist observes the gait of a patient rehabilitating from a traumatic brain injury. The patient has significant spasticity in the lower extremities and demonstrates a scissoring gait pattern. The MOST likely cause of the gait deviation is increased tone in the:
Correct Answer: A
Rationale: The correct answer is A) hip adductors. In a scissoring gait pattern, the legs cross midline due to increased tone in the hip adductors, causing them to pull the legs towards each other during walking. This results in a narrow-based, stiff-legged gait characteristic of spasticity. Option B) hip abductors would actually help to counteract the adduction and prevent the legs from crossing over excessively. Option C) knee flexors and Option D) ankle dorsiflexors are not primarily responsible for the scissoring gait seen in this patient. Educationally, understanding gait deviations related to spasticity is crucial for healthcare professionals like physical therapists to effectively assess and treat patients with neurological conditions. Recognizing the specific muscle groups involved in abnormal gait patterns can guide interventions aimed at improving mobility and quality of life for patients undergoing rehabilitation.
Question 3 of 5
A patient with type 2 diabetes presents with signs of peripheral neuropathy. Which physical therapy intervention would be MOST appropriate?
Correct Answer: B
Rationale: In this scenario, the most appropriate physical therapy intervention for a patient with type 2 diabetes presenting signs of peripheral neuropathy is option B) Education on foot care. Rationale for correct answer: Peripheral neuropathy in diabetes can lead to decreased sensation in the feet, increasing the risk of foot ulcers and injuries. Education on foot care is crucial as it empowers the patient to prevent complications by learning proper foot hygiene, skin inspection techniques, appropriate footwear selection, and strategies to avoid trauma. Rationale for incorrect options: A) Ultrasound therapy: While ultrasound therapy can be beneficial for certain conditions such as soft tissue injuries, it does not directly address the prevention or management of foot complications associated with peripheral neuropathy in diabetes. C) Electrical stimulation for pain relief: While electrical stimulation can help manage pain, it does not address the preventive aspect of foot care which is crucial in this case. D) Massage therapy: Massage therapy may provide temporary relief but does not address the core issue of preventing foot complications in diabetes. Educational context: Educating patients with diabetes about foot care is a fundamental aspect of managing peripheral neuropathy and preventing serious complications. By empowering patients with knowledge and skills to care for their feet, physical therapists can significantly improve the patient's quality of life and reduce the risk of adverse outcomes associated with peripheral neuropathy. It is essential for healthcare providers to prioritize patient education as part of a comprehensive approach to managing diabetes-related complications.
Question 4 of 5
A physical therapist evaluates a patient with multiple sclerosis (MS) experiencing fatigue. Which intervention is MOST appropriate to improve endurance?
Correct Answer: B
Rationale: In this case, the most appropriate intervention to improve endurance in a patient with multiple sclerosis (MS) experiencing fatigue is option B) Aquatic therapy. Aquatic therapy is a highly effective intervention for individuals with MS as it provides a supportive environment that reduces the impact of gravity, making movements easier and less fatiguing. The buoyancy of water helps to support the patient's body weight, allowing for increased mobility and endurance building without excessive strain on the muscles and joints. High-intensity interval training (option A) may not be suitable for a patient with MS experiencing fatigue, as it can be too intense and may exacerbate symptoms. Progressive resistance training (option C) focuses more on strength building rather than endurance, which may not directly address the patient's fatigue concerns. Treadmill walking at 85% HR max (option D) can be too strenuous for a patient experiencing fatigue and may not be well-tolerated. In an educational context, understanding the specific needs and limitations of patients with MS is crucial for healthcare professionals. Aquatic therapy is a valuable tool in rehabilitation for individuals with MS, as it allows for safe and effective endurance training while minimizing the risk of injury or exacerbating symptoms. Educating therapists on the benefits of aquatic therapy and its tailored approach for patients with MS can significantly improve outcomes and quality of care.
Question 5 of 5
During a cardiovascular assessment, the nurse notes jugular vein distension (JVD) in a patient sitting at a 45-degree angle. What does this finding indicate?
Correct Answer: C
Rationale: In a cardiovascular assessment, the presence of jugular vein distension (JVD) in a patient sitting at a 45-degree angle typically indicates heart failure. When the heart fails to effectively pump blood forward, increased pressure builds up in the venous system, leading to JVD. This finding is due to the back-up of blood in the venous system, causing the jugular veins to become visibly distended. Option A: Jugular vein distension at 45 degrees is not a normal finding. It suggests underlying cardiovascular issues rather than being a typical response to positioning. Option B: Dehydration would not directly cause jugular vein distension. Dehydration might lead to decreased venous return, but it would not manifest as visible JVD in this scenario. Option D: While a pulmonary embolism can cause strain on the heart and lead to right-sided heart failure, jugular vein distension alone is more strongly indicative of heart failure in this context. Educationally, understanding the significance of JVD in cardiovascular assessment is crucial for nurses to recognize early signs of heart failure and provide timely interventions. Recognizing this clinical manifestation can guide appropriate nursing interventions and facilitate prompt communication with healthcare providers for further evaluation and management.