ATI RN
Vital Signs Health Assessment Questions
Question 1 of 5
During a cardiovascular assessment, the nurse observes that the patient has a rapid, irregular pulse. What is the most likely diagnosis?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
The nurse is performing an abdominal assessment and notes a positive Murphy's sign. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
Considered the 5th vital sign:
Correct Answer: D
Rationale: Pain, is correct as its widely recognized as the fifth vital sign in modern healthcare, alongside temperature, pulse, respiration, and blood pressure. Pain assessment (often via a 0-10 scale) helps evaluate patient comfort and guide treatment, especially post-surgery or in chronic conditions. Height and weight, are metrics, not vital signs. Respiration, is a core vital sign (not fifth). Body mass index, derived from height and weight, isnt directly measured as a vital sign. Since the 1990s, pains inclusion reflects its impact on health status, making D the correct answer per nursing standards emphasizing holistic care.
Question 4 of 5
A patient is experiencing dyspnea. What is the nurses priority action?
Correct Answer: B
Rationale: Dyspnea (shortness of breath) requires improving lung expansion. Elevating the head of the bed allows abdominal organs to shift downward, giving the diaphragm more room to move, easing breathing. Removing pillows might flatten the patient, worsening lung expansion. Elevating the foot could increase abdominal pressure on the diaphragm, exacerbating dyspnea. Taking blood pressure is secondary to addressing the immediate respiratory need. Choice B is the priority as it directly improves oxygenation, a critical nursing intervention rooted in anatomical and physiological principles for respiratory distress management.
Question 5 of 5
A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient?
Correct Answer: A
Rationale: Shallow breathing obscures visual counting, requiring alternatives. Auscultating lung sounds detects air movement, allowing a 30-second count doubled to 60 seconds, a reliable method. Palpating thorax excursion is less precise for rate. Pulse oximetry measures oxygen, not rate directly. Arterial blood gases assess gases, not frequency. Choice A is correct, per nursing practice, ensuring accurate respiratory assessment when inspection fails.