ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A physical therapist educates a patient on how to use a mechanical lift to transfer a family member from bed to a wheelchair. The therapist explains that the MOST important instruction for the caregiver is to:
Correct Answer: B
Rationale: The correct answer is B: Position the sling appropriately under the patient. This is crucial as an improperly positioned sling can lead to discomfort or injury for the patient during the transfer. By ensuring the sling is correctly placed, the caregiver can provide proper support and enhance the safety of the transfer. Placing the patient's arms outside of the sling (choice A) is important but not as critical as positioning the sling correctly. Locking the lift after positioning the patient in the wheelchair (choice C) is important for safety but not as crucial as ensuring the sling placement. Maintaining good body mechanics during the transfer (choice D) is also important for the caregiver's safety, but the priority should be on positioning the sling properly to ensure the patient's safety and comfort.
Question 2 of 5
A physical therapist evaluates a patient following a transtibial amputation. Which factor is MOST likely to contribute to knee instability during gait?
Correct Answer: B
Rationale: The correct answer is B: Prosthesis aligned in excessive dorsiflexion. Excessive dorsiflexion can lead to increased knee flexion during stance phase of gait, causing knee instability. Weak hip abductors (A) may contribute to Trendelenburg gait but not knee instability. A prosthesis that is too short (C) may result in decreased step length but not necessarily knee instability. A socket too tight (D) can cause discomfort and skin breakdown but is unlikely to directly lead to knee instability.
Question 3 of 5
The nurse is performing an otoscopic examination on a child and notes that the tympanic membrane is red and bulging. What condition does this finding suggest?
Correct Answer: B
Rationale: The correct answer is B: Otitis media. In otitis media, the middle ear becomes infected and inflamed, causing the tympanic membrane to appear red and bulging. This can be due to the accumulation of fluid and pus behind the eardrum. Otitis externa (choice A) involves inflammation of the ear canal, not the middle ear. A perforated eardrum (choice C) would show a hole or tear in the membrane rather than redness and bulging. Choice D is incorrect as a red and bulging tympanic membrane is not a normal finding in children.
Question 4 of 5
Which of the following findings during a respiratory assessment is considered abnormal?
Correct Answer: C
Rationale: The correct answer is C: Use of accessory muscles during breathing. This finding is considered abnormal because it indicates increased work of breathing and respiratory distress. Accessory muscles should not be used during normal breathing. A: Symmetrical chest expansion, B: Resonance on percussion, and D: Clear breath sounds are all normal findings indicating proper lung function and ventilation.
Question 5 of 5
The nurse is assessing a patient's mental status and observes that the patient is disoriented to time but oriented to person and place. How should this finding be documented?
Correct Answer: A
Rationale: The correct answer is A because the patient is only disoriented to time, not person and place. Being alert and oriented to person and place but not time indicates a specific level of disorientation. Choice B is incorrect as the patient is not disoriented to all spheres. Choice C is incorrect as the patient is not confused but disoriented. Choice D is incorrect as the patient is not fully oriented due to being disoriented to time. Therefore, the correct documentation should accurately reflect the patient's state of being alert and oriented to person and place but not time.