ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During a cardiovascular assessment, the nurse notes a bounding peripheral pulse. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Hypervolemia. Bounding peripheral pulses are typically associated with increased blood volume, which is a characteristic of hypervolemia. When the body has an excess of fluid, the pulse feels strong and full due to the increased volume of blood circulating in the arteries. In contrast: A: Hypovolemia is characterized by decreased blood volume, leading to weak and thready pulses. B: Aortic stenosis causes obstruction of blood flow from the left ventricle into the aorta, resulting in a weak, delayed, or diminished pulse. D: Atrial fibrillation is an irregular heart rhythm that can result in an irregular pulse, but it does not typically cause bounding pulses.
Question 2 of 5
The nurse is performing a cardiovascular assessment and notes a gallop rhythm on auscultation. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a gallop rhythm on auscultation is most likely associated with congestive heart failure. This rhythm indicates the presence of an additional heart sound, usually an S3 or S4, which can be heard in conditions where there is volume overload or increased filling pressures in the heart, such as in congestive heart failure. The S3 gallop is typically associated with volume overload, while the S4 gallop is associated with increased resistance to ventricular filling. Aortic stenosis, mitral valve prolapse, and tricuspid regurgitation typically present with different auscultatory findings such as murmurs or clicks, rather than a gallop rhythm.
Question 3 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg sign is a test of proprioception. A positive Romberg sign indicates impaired proprioception, where the patient is unable to maintain balance with eyes closed due to dysfunction in proprioceptive pathways. This is the correct answer (C). Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar ataxia presents with a different set of symptoms. Choice D is incorrect as sensory neuropathy affects sensation, not proprioception.
Question 4 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the hip. What is the next step in the assessment?
Correct Answer: A
Rationale: The correct next step in this situation is to palpate the hip for tenderness. This is important to assess for any signs of inflammation, injury, or underlying musculoskeletal issues causing the limited range of motion. Palpation helps identify specific areas of discomfort or tenderness that may provide clues to the root cause of the limited range of motion. Performing passive range of motion (choice B) would be premature without first identifying any tenderness. Auscultating the joint for crepitus (choice C) is not necessary at this stage as it is more relevant in assessing joint sounds, not range of motion. Referring the patient for imaging (choice D) would be a later step after a more thorough assessment to confirm any suspected pathology.
Question 5 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg test evaluates a person's ability to maintain balance with eyes closed. A positive Romberg sign indicates proprioceptive dysfunction, as the patient relies on visual input for balance. This suggests issues with sensory perception and coordination. Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar dysfunction would present with different signs. Choice D is incorrect as motor weakness would not be specifically indicated by a positive Romberg sign.