ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
Correct Answer: A
Rationale: The correct answer is A: It is a splenic rub. The rough grating noise heard on examination is characteristic of a splenic rub, which occurs when the peritoneum overlying the spleen rubs against the spleen itself. This is often associated with conditions like splenic infarction or abscess. In Cody's case, with his history of leukemia and an enlarged spleen, this finding is concerning and warrants further investigation. Summary of other choices: B: It is not a variant of bowel noise as bowel noises are typically more high-pitched and gurgling in nature. C: It is not borborygmi, which refers to the normal sounds produced by the movement of gas and fluid in the intestines. D: It is not a vascular noise as those are usually associated with blood flow abnormalities and are not typically heard in the left upper quadrant.
Question 2 of 5
The nurse recognizes that the bell of the stethoscope is used to detect which type of sounds?
Correct Answer: B
Rationale: The correct answer is B because low-pitched sounds like heart murmurs are best detected using the bell of the stethoscope. The bell is designed to pick up low-frequency sounds with more clarity and resonance due to its shape and size. Heart murmurs typically fall into the category of low-pitched sounds, making the bell ideal for their detection. Choice A is incorrect because high-pitched sounds like breath sounds are better detected using the diaphragm of the stethoscope, not the bell. Choice C is incorrect as sounds over a large surface area would be better detected using the diaphragm as well. Choice D is incorrect because the amplitude of the sound does not determine whether the bell or diaphragm is used; it is more about the frequency or pitch of the sound.
Question 3 of 5
The nurse is conducting a respiratory assessment. Which finding requires immediate attention?
Correct Answer: D
Rationale: The correct answer is D: Use of accessory muscles during breathing. This finding indicates respiratory distress and requires immediate attention as it suggests the patient is having difficulty breathing effectively. Accessory muscle use signifies increased work of breathing and potential respiratory compromise. A: A respiratory rate of 16 breaths per minute is within the normal range. B: An SpO2 of 92% on room air is slightly below the normal range but may not require immediate intervention. C: Bilateral lung sounds clear to auscultation indicate normal breath sounds and do not suggest imminent respiratory distress.
Question 4 of 5
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Correct Answer: D
Rationale: The correct answer is D: Midbrain. Decerebrate posturing is a specific type of abnormal posturing that indicates damage to the midbrain. In decerebrate posturing, the arms are extended and pronated, and the legs are extended with plantar flexion. This posture is a result of the disruption of the neural pathways between the brain and spinal cord that pass through the midbrain. Damage to the cortex (choice A) would not result in decerebrate posturing. The diencephalon (choice B) is responsible for regulating many important functions, but it does not directly control motor responses like posturing. The medulla (choice C) is primarily involved in regulating vital functions like breathing and heart rate, not motor posturing. Therefore, the correct answer is D, midbrain, as damage to this area leads to decerebrate posturing.
Question 5 of 5
A physical therapist completes an examination on a five-year-old boy diagnosed with Duchenne muscular dystrophy. The referral indicates that the boy was diagnosed with the disease less than one year ago. Assuming a normal progression, which of the following would be expected?
Correct Answer: B
Rationale: The correct answer is B: Proximal muscle weakness. In Duchenne muscular dystrophy, proximal muscle weakness is typically one of the earliest signs due to the progressive degeneration of muscle fibers. This weakness starts in the pelvic girdle and lower extremities before affecting the upper extremities. Distal muscle weakness (choice A) occurs later in the disease progression. Impaired respiratory function (choice C) is also a common feature in Duchenne muscular dystrophy but usually develops later in the disease course. Inability to perform activities of daily living (choice D) may occur eventually, but proximal muscle weakness is the more immediate and expected outcome in a newly diagnosed five-year-old with Duchenne muscular dystrophy.