ATI RN
Assess Vital Signs Questions
Question 1 of 5
During a cardiovascular assessment, the nurse auscultates a murmur. How should the nurse describe this finding?
Correct Answer: D
Rationale: The correct answer is D because a murmur is described as a whooshing or swishing sound heard over the heart due to turbulent blood flow. This sound is typically heard during systole or diastole, which aligns with the timing of heart sounds. A: A palpable vibration is more characteristic of a thrill, not a murmur. B: An extra heart sound refers to S3 or S4, not a murmur. C: A high-pitched sound during inspiration is more indicative of wheezing in the lungs, not a murmur.
Question 2 of 5
The nurse is auscultating the lungs and hears a high-pitched, musical sound on expiration. What does this sound indicate?
Correct Answer: A
Rationale: The correct answer is A: Wheezing. Wheezing is a high-pitched, musical sound on expiration caused by narrowing of airways. This indicates obstruction in the lower respiratory tract, commonly seen in conditions like asthma or COPD. Crackles (B) are discontinuous, crackling sounds heard on inspiration and indicate fluid in the alveoli. Pleural friction rub (C) is a grating, rubbing sound heard during inspiration and expiration, suggesting inflammation of the pleura. Stridor (D) is a high-pitched, harsh sound heard on inspiration, indicating upper airway obstruction.
Question 3 of 5
Which finding during an abdominal assessment suggests the presence of ascites?
Correct Answer: B
Rationale: The correct answer is B: Shifting dullness on percussion. Ascites is the accumulation of fluid in the peritoneal cavity. When the patient is in a supine position, the fluid settles by gravity and causes dullness upon percussion in the dependent areas. Shifting dullness occurs when the patient is turned to the side, causing the fluid to shift and the dullness to move. This finding is specific to ascites. A: Hyperresonance on percussion is associated with bowel gas and is typically heard in cases of bowel obstruction. C: Borborygmi on auscultation refers to hyperactive bowel sounds and is not specific to ascites. D: Rebound tenderness on palpation indicates peritoneal irritation, often seen in cases of peritonitis, not ascites. In summary, shifting dullness on percussion is the key finding in assessing ascites due to the movement of fluid in the peritoneal cavity.
Question 4 of 5
During a neurological assessment, the nurse observes that the patient has difficulty pronating and supinating the hands rapidly. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A cerebellar dysfunction. This finding indicates cerebellar dysfunction because the cerebellum is responsible for coordinating rapid, smooth movements such as pronation and supination. A dysfunction in the cerebellum can result in impaired coordination and control of these movements. Incorrect choices: B: A cranial nerve deficit - Cranial nerves do not directly control pronation and supination. C: Impaired proprioception - Proprioception is the sense of body position and movement, not directly related to pronation and supination. D: Weakness in the upper extremities - Pronation and supination are more about coordination than strength.
Question 5 of 5
The following information is best placed in which category? 'The patient has had three cesarean sections.'
Correct Answer: B
Rationale: The correct answer is B: Surgeries. The statement 'The patient has had three cesarean sections' pertains to a surgical procedure rather than adult illnesses, obstetrics/gynecology, or psychiatric conditions. Cesarean sections are a type of surgery performed during childbirth, not related to adult illnesses or psychiatric disorders. Therefore, the information best fits under the category of Surgeries.