ATI RN
Assess Vital Signs Questions
Question 1 of 5
A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely?
Correct Answer: A
Rationale: The correct answer is A: Otosclerosis of the left ear. In otosclerosis, there is abnormal bone growth in the middle ear that affects sound conduction. In this case, bone conduction being greater than air on the left indicates a conductive hearing loss, which is consistent with otosclerosis. The Weber test showing the sound better on the left ear suggests a lateralization towards the affected ear, supporting the diagnosis. Incorrect choices: B: Exposure to chronic loud noise of the right ear would likely result in sensorineural hearing loss, not a conductive hearing loss as seen in this case. C: Otitis media of the right ear would also lead to conductive hearing loss, but the abnormal findings are consistent with left ear involvement, making this choice incorrect. D: Perforation of the right eardrum would result in a conductive hearing loss in the right ear, not the left ear as observed in this patient.
Question 2 of 5
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A. The significant change in blood pressure from 128/68 to 160/50, along with a significant decrease in pulse from 110 to 55, and a decrease in respirations from 26 to 14, indicates potential signs of deteriorating condition. A drop in blood pressure paired with a significant decrease in pulse and respirations could signify shock, which is a life-threatening condition that requires immediate intervention. Option B shows an increase in pulse and respirations, but the blood pressure remains within an acceptable range. Option C shows a slight increase in blood pressure with minimal changes in pulse and respirations. Option D shows a moderate decrease in pulse and a significant increase in respirations, but the blood pressure remains relatively stable. In summary, option A is the most concerning as it shows a combination of significant changes in blood pressure, pulse, and respirations, indicating a potential deterioration in the patient's condition.
Question 3 of 5
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway using which method?
Correct Answer: C
Rationale: The correct answer is C: Jaw thrust maneuver. This method is used to open the airway in a suspected cervical spine injury. Step 1: Place hands on either side of the patient's face, positioning the thumbs under the jaw. Step 2: Use the thumbs to gently lift the jaw forward, keeping the head in a neutral position. This technique helps maintain alignment of the cervical spine. The other choices are incorrect because A: Flexed position may worsen spinal injury, B: Head tilt-chin lift can cause further trauma in cervical spine injury, and D: Modified head tilt-chin lift is not recommended for suspected spinal injuries.
Question 4 of 5
The nurse is performing a head-to-toe assessment. Which sequence of assessment techniques is correct for the abdominal region?
Correct Answer: C
Rationale: The correct sequence for assessing the abdominal region is inspection, auscultation, percussion, palpation (Choice C). Inspection allows visual assessment for any abnormalities. Auscultation should be done before palpation to prevent altering bowel sounds. Percussion helps assess for organ size and density. Palpation is done last to assess for tenderness, masses, and organ shape. Explanation for why the other choices are incorrect: A: Incorrect because palpation should be done after auscultation. B: Incorrect because auscultation should be done before palpation. D: Incorrect because palpation should be the last step in the sequence.
Question 5 of 5
During a cardiovascular assessment, the nurse auscultates a murmur. How should the nurse describe this finding?
Correct Answer: D
Rationale: The correct answer is D because a murmur is described as a whooshing or swishing sound heard over the heart due to turbulent blood flow. This sound is typically heard during systole or diastole, which aligns with the timing of heart sounds. A: A palpable vibration is more characteristic of a thrill, not a murmur. B: An extra heart sound refers to S3 or S4, not a murmur. C: A high-pitched sound during inspiration is more indicative of wheezing in the lungs, not a murmur.