ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A physical therapist reviews the medical record of a patient diagnosed with Parkinson's disease. Which clinical finding would the therapist MOST likely observe?
Correct Answer: A
Rationale: The correct answer is A: Hypertonicity. In Parkinson's disease, there is a loss of dopamine-producing cells, leading to increased muscle tone or hypertonicity. This results in stiffness and rigidity of muscles, making movements slow and difficult. Hypotonicity (B) refers to decreased muscle tone and is not typically seen in Parkinson's. Hyperreflexia (C) is an exaggerated reflex response, which is not a common feature of Parkinson's. Hyporeflexia (D) is reduced reflex response, which is not typically associated with Parkinson's disease. Hence, the most likely clinical finding in a patient with Parkinson's disease would be hypertonicity.
Question 2 of 5
A physical therapist works with a patient who has a deep partial-thickness burn on the upper extremity. Which dressing would be MOST appropriate for this type of wound?
Correct Answer: B
Rationale: The correct answer is B: Silver sulfadiazine dressing. This choice is correct because silver sulfadiazine has antimicrobial properties that can help prevent infection in deep partial-thickness burns. It also provides a moist environment for wound healing. A: Hydrocolloid dressing is not ideal for deep partial-thickness burns as it may not provide enough antimicrobial protection. C: Gauze dressing with saline is not the best choice as it can dry out the wound and may not provide adequate protection against infection. D: Transparent film dressing is not suitable for deep partial-thickness burns as it does not provide the necessary antimicrobial properties and may not allow proper wound healing.
Question 3 of 5
Which physical assessment finding is most consistent with dehydration?
Correct Answer: C
Rationale: The correct answer is C: Dry, cracked lips. Dehydration leads to decreased fluid volume in the body, causing dryness and cracking of the lips due to lack of moisture. Moist mucous membranes (choice A) are typically seen in hydrated individuals. Increased skin turgor (choice B) is a sign of dehydration, but dry, cracked lips are more specific. Bounding peripheral pulses (choice D) are associated with conditions like fluid overload or increased blood volume, not dehydration. Dry, cracked lips are a key indicator of dehydration due to the direct impact of fluid depletion on mucous membranes.
Question 4 of 5
The nurse is conducting a health assessment on a patient with suspected meningitis. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: The correct answer is B: Nuchal rigidity. This is because nuchal rigidity, or neck stiffness, is a classic sign of meningitis due to inflammation of the meninges. It is often accompanied by headache, fever, and altered mental status. The other choices are not typically associated with meningitis. A Babinski sign is indicative of upper motor neuron lesion, hyperactive deep tendon reflexes can be seen in conditions like hyperthyroidism or upper motor neuron disorders, and asymmetrical pupils could indicate a neurological deficit but are not specific to meningitis. Therefore, nuchal rigidity is the most consistent finding in a patient with suspected meningitis.
Question 5 of 5
During a pain assessment, the patient rates their pain as 8 on a scale of 0 to 10. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Administer prescribed pain medication. The priority action is to address the patient's pain to provide relief and improve comfort. Administering pain medication is essential to manage the patient's pain effectively. Reassessing the pain in 30 minutes (choice A) delays pain relief. Simply documenting the pain level as reported (choice C) without taking action does not address the patient's immediate needs. Applying a warm compress (choice D) may provide some comfort but does not directly address the pain intensity reported by the patient. Administering pain medication is the most appropriate and immediate action to address the patient's discomfort.