ATI RN
Assessing Vital Signs Questions
Question 1 of 5
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
Correct Answer: A
Rationale: The correct answer is A: Asthma. The assessment findings described are classic signs of an asthma exacerbation. Tachypnea, prolonged expiration, intercostal retractions, and expiratory wheezes are all indicative of narrowed airways and difficulty breathing, which are characteristic of asthma. The use of accessory neck muscles indicates increased effort to breathe. Decreased breath sounds are due to air trapping in the lungs. In contrast, choices B, C, and D do not typically present with the combination of symptoms described. Atelectasis usually presents with decreased breath sounds and crackles. Lobar pneumonia typically presents with fever, productive cough, and focal chest signs. Heart failure presents with bilateral crackles, edema, and jugular venous distension.
Question 2 of 5
Which of these statements describes the closure of the valves in a normal cardiac cycle?
Correct Answer: C
Rationale: The correct answer is C because in a normal cardiac cycle, the closure of the valves follows a specific sequence. The mitral valve closes slightly before the tricuspid valve due to the ventricular pressure changes. The closure of the mitral valve marks the beginning of systole, while the tricuspid valve closes shortly after. Choices A and B are incorrect as they do not accurately describe the sequence of valve closure. Choice D is incorrect because the tricuspid and pulmonic valves do not close at the same time in a normal cardiac cycle.
Question 3 of 5
During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
Correct Answer: C
Rationale: The correct answer is C: Displacement of the heart from elevation of the diaphragm. During pregnancy, the growing uterus pushes the diaphragm upwards, causing the heart to be displaced upwards and laterally. This displacement results in the apical impulse being palpated at a higher position, such as the fourth left intercostal space lateral to the midclavicular line. This finding is a normal physiological change due to pregnancy and does not indicate any cardiac pathology. Explanation of other choices: A: Right ventricular hypertrophy - This is unlikely in a pregnant patient without underlying cardiac conditions. B: Increased volume and size of the heart as a result of pregnancy - While the heart may undergo some changes during pregnancy, palpating the apical impulse at a higher position is specifically due to displacement of the heart by the elevated diaphragm, not increased heart size. D: Increased blood flow through the internal mammary artery - This choice is unrelated to the displacement of the heart and the
Question 4 of 5
A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a 'bag of worms' in the left scrotum, superior to the testicles. Which of the following is most likely?
Correct Answer: B
Rationale: The correct answer is B: Varicocele. Varicocele is characterized by dilated and tortuous veins within the spermatic cord, giving a 'bag of worms' sensation. It typically occurs on the left side and is more common in young men. Rationale: 1. Hydrocele of the spermatic cord (A) presents as a fluid-filled sac around the spermatic cord, not as dilated veins. 2. Testicular carcinoma (C) typically presents as a painless lump within the testicle, not as dilated veins in the spermatic cord. 3. A normal vas deferens (D) is a normal part of the male reproductive anatomy and would not present as a 'bag of worms' sensation. In summary, the presence of dilated and tortuous veins in the left scrotum, superior to the testicles, is most indicative of a varicocele, making it the correct choice.
Question 5 of 5
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 5 seconds in an adult is considered delayed and may indicate poor perfusion or circulatory issues. The nurse should investigate further to determine the underlying cause. Option A is incorrect as frostbite history does not directly relate to the capillary refill time in this scenario. Option B is incorrect as venous insufficiency does not typically affect capillary refill time. Option D is incorrect because a capillary refill time of 5 seconds is not considered normal in adults and warrants further evaluation.