ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
An adult patient is assessed as having an apical pulse of 140. How would the nurse document this finding?
Correct Answer: B
Rationale: An apical pulse of 140 is tachycardia , per the answer key, exceeding 100 bpm. Bradycardia is <60, dysrhythmia irregularity, normal 60-100. Nurses document this to flag potential stress or pathology.
Question 2 of 5
Mrs. Jaeger is a 67–year-old who went through menopause at age 55. She has now had some vaginal bleeding. Which of the following should be considered?
Correct Answer: D
Rationale: The correct answer is D, "All of the above." 1. Endometrial cancer is a concern due to postmenopausal bleeding. 2. Hormone replacement therapy can lead to abnormal bleeding. 3. Uterine or cervical polyps can also cause vaginal bleeding in postmenopausal women. Therefore, all options should be considered in Mrs. Jaeger's case to rule out any serious underlying conditions.
Question 3 of 5
Which is the most effective pattern of palpation for breast cancer?
Correct Answer: C
Rationale: The correct answer is C because examining in lines resembling the back and forth pattern of mowing a lawn allows for systematic coverage of the entire breast, ensuring no area is missed. This pattern helps in detecting any abnormalities or lumps consistently. A: Beginning at the nipple and making an ever-enlarging spiral may miss certain areas of the breast. B: Dividing the breast into quadrants may lead to missing areas between the quadrants. D: Beginning at the nipple and palpating outward in a stripe pattern may not cover the entire breast evenly, potentially missing abnormalities.
Question 4 of 5
A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these?
Correct Answer: D
Rationale: The correct answer is D: Heart failure. Late inspiratory crackles at the bases suggest fluid accumulation in the alveoli, typical of heart failure. Explanation: Heart failure can cause pulmonary edema leading to crackles. Asthma (A) typically presents with wheezing, not crackles. COPD (B) usually presents with expiratory wheezes. Bronchiectasis (C) is characterized by chronic productive cough and not typically late inspiratory crackles. In summary, the presence of late inspiratory crackles in the lower third of the chest points towards heart failure due to pulmonary edema.
Question 5 of 5
The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:
Correct Answer: C
Rationale: The correct answer is C because the Denver II screening test is indeed a tool designed to detect children who are slow in development across various areas, such as motor skills, social skills, and language development. It is not specific to intellectual ability or predicting future school problems, as suggested in option D. It also does not solely focus on speech disorders, as mentioned in option B. While the Denver II assesses cognitive, physical, and psychological development, it is primarily used to identify developmental delays rather than diagnosing specific disorders, making option A incorrect.