ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A physical therapist evaluates a patient with suspected carpal tunnel syndrome. Which clinical test is MOST appropriate to confirm the diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. This test involves the patient flexing their wrists for 60 seconds to reproduce symptoms of carpal tunnel syndrome. This maneuver compresses the median nerve, causing numbness and tingling in the fingers. Phalen's test is specific for carpal tunnel syndrome. Other choices are not specific to this condition. Finkelstein test is for De Quervain's tenosynovitis, Tinel's sign at the elbow is for ulnar nerve entrapment, and Empty can test is for rotator cuff pathology.
Question 2 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 3 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 4 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 5 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.