ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is performing a pain assessment and asks the patient to describe the location of their pain. Which dimension of pain is being assessed?
Correct Answer: C
Rationale: The correct answer is C: Location. In pain assessment, evaluating the location of pain helps in determining the underlying cause and potential treatment options. Understanding the exact area of pain can provide crucial information for diagnosis and management. Intensity (A) refers to the severity of pain, quality (B) describes the characteristics of pain, and duration (D) indicates how long the pain lasts. These dimensions are important but in this case, the focus is on identifying the specific site of pain to guide further assessment and intervention.
Question 5 of 5
The nurse is assessing a patient's skin and notes a raised, rough lesion with a wart-like appearance. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Seborrheic keratosis. This diagnosis is likely due to the lesion's raised, rough, and wart-like appearance, which is characteristic of seborrheic keratosis. Seborrheic keratosis is a common benign skin growth that typically appears in older individuals and presents as brown, black, or tan growths with a waxy, stuck-on appearance. It is important to note that seborrheic keratosis is non-cancerous and does not require immediate medical treatment. Summary: - B: Basal cell carcinoma typically presents as a pearly or waxy bump, not a raised, rough lesion with a wart-like appearance. - C: Actinic keratosis is a precancerous skin condition characterized by rough, scaly patches, not a raised, wart-like lesion. - D: Squamous cell carcinoma usually appears as a firm red nodule or a flat lesion with a scaly