ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?
Correct Answer: C
Rationale: The correct answer is C: Ischemia. The elderly woman's history of coronary bypass surgery suggests a higher risk for vascular issues like mesenteric ischemia. The severe, diffuse abdominal pain that is not exacerbated by palpation is a classic presentation of mesenteric ischemia. This condition results from inadequate blood supply to the intestines and can lead to severe abdominal pain. Malingering (A) is unlikely as there is a legitimate medical history. Neuropathy (B) typically presents with different symptoms such as numbness or tingling rather than severe abdominal pain. Physical abuse (D) does not align with the clinical presentation and medical history.
Question 2 of 5
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Head turned to the side. This position can potentially increase intracranial pressure by obstructing venous drainage and impeding blood flow. The rationale is to maintain cerebral perfusion and reduce the risk of complications. A: Head midline is correct as it promotes proper alignment and reduces strain on the neck muscles. C: Neck in neutral position is correct to prevent additional pressure on the neck and optimize blood flow. D: Head of bed elevated 30 to 45 degrees is correct to facilitate venous drainage and reduce intracranial pressure.
Question 3 of 5
The nurse is teaching a patient about hypertension management. Which statement by the patient indicates a need for further teaching?
Correct Answer: B
Rationale: Correct Answer: B Rationale: Choice B indicates a misunderstanding as stopping medications once blood pressure is normal can lead to uncontrolled hypertension. Patients with hypertension typically require long-term medication management to maintain blood pressure within a healthy range. This choice reflects a need for further teaching to emphasize the importance of medication adherence. Summary: A: Checking blood pressure regularly is a good practice for hypertension management. C: Reducing salt and processed food intake helps in managing hypertension. D: Incorporating exercise into daily routine is beneficial for hypertension management.
Question 4 of 5
The nurse is performing an abdominal assessment and notes a bruit over the aorta. What does this finding indicate?
Correct Answer: B
Rationale: Step 1: A bruit is an abnormal sound caused by turbulent blood flow. Step 2: The presence of a bruit over the aorta indicates turbulent blood flow, possibly due to atherosclerosis or an aneurysm. Step 3: This finding is significant and requires further assessment and monitoring. Step 4: Therefore, choice B is correct as it accurately reflects the indication of a bruit over the aorta. Summary: Choices A, C, and D are incorrect because a bruit is not a normal vascular sound, does not indicate absence of bowel sounds, and is not related to increased peristalsis.
Question 5 of 5
Which of the following assessment findings is most consistent with chronic venous insufficiency?
Correct Answer: B
Rationale: The correct answer is B: Brown discoloration around the ankles. Chronic venous insufficiency is characterized by impaired venous return, leading to pooling of blood in the lower extremities. This results in hemosiderin deposition, causing brown discoloration around the ankles known as hemosiderin staining. Pale, cool skin (choice A) is more indicative of arterial insufficiency. Diminished pulses (choice C) are associated with arterial occlusive disease. Intermittent claudication (choice D) is a symptom of peripheral artery disease.