ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
During a neurological assessment, the nurse evaluates the patient's deep tendon reflexes (DTRs). A normal response is documented as:
Correct Answer: C
Rationale: The correct answer is C (2+). A normal deep tendon reflex response is typically graded as 2+. This indicates a normal response with brisk, expected reflexes. Option A (0) suggests no response, which would be abnormal. Option B (1+.) indicates a diminished response, while option D (3+.) suggests an exaggerated response, both of which are abnormal findings. Therefore, the correct answer is C as it represents the standard, expected reflex response during a neurological assessment.
Question 2 of 5
The nurse is assessing a patient's capillary refill time. What is the normal finding for this assessment?
Correct Answer: B
Rationale: The correct answer is B: Less than 2 seconds. Capillary refill time measures the time it takes for blood to return to the capillaries after pressure is applied and released. A normal finding is less than 2 seconds, indicating adequate peripheral perfusion. Choices A, C, and D are incorrect as they exceed the normal capillary refill time, which could suggest inadequate circulation and potential perfusion issues. Choice A (<1 second) may indicate hypervolemia or vasodilation, while choices C (>3 seconds) and D (>4 seconds) may indicate hypovolemia or vasoconstriction, respectively. Hence, the correct answer is less than 2 seconds, as it indicates normal capillary refill time and adequate blood flow.
Question 3 of 5
During a skin assessment, the nurse notes that the patient has petechiae. What is the primary cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Capillary bleeding. Petechiae are tiny, pinpoint, round spots that appear on the skin due to bleeding under the skin. This is caused by capillaries leaking blood into the skin, leading to the characteristic appearance of petechiae. Dilated capillaries (A) do not directly cause petechiae. Increased melanin production (C) results in skin pigmentation changes, not petechiae. Loss of collagen (D) may lead to skin changes like sagging, but it is not the primary cause of petechiae.
Question 4 of 5
During a cardiac assessment, the nurse notes a high-pitched, scratchy sound heard during both systole and diastole. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Pericardial friction rub, as it is a high-pitched, scratchy sound heard during both systole and diastole, indicating inflammation of the pericardium. This sound is produced by the rubbing of inflamed pericardial layers during the cardiac cycle. B: Aortic stenosis produces a systolic murmur. C: Mitral valve regurgitation produces a holosystolic murmur. D: Heart murmur is a generic term and does not specifically describe the high-pitched, scratchy sound heard during both systole and diastole.
Question 5 of 5
A 50-year-old woman presents with a complaint of severe headaches that occur in the morning and are associated with nausea and vomiting. She also reports blurred vision. Neurological examination reveals papilledema. Which of the following is the most likely diagnosis?
Correct Answer: D
Rationale: The correct answer is D, Intracranial hypertension. This condition is characterized by increased pressure within the skull, leading to symptoms such as morning headaches, nausea, vomiting, blurred vision, and papilledema. The patient's presentation of severe morning headaches with associated symptoms and papilledema is classic for intracranial hypertension. Migraine (A) typically presents with pulsating headaches without neurological signs. Cluster headache (B) is characterized by severe unilateral headaches with autonomic features but not typically associated with papilledema. Tension-type headache (C) is usually bilateral, mild to moderate in intensity, and not associated with papilledema. In summary, the patient's symptoms and signs are most consistent with intracranial hypertension due to the presence of morning headaches, nausea, vomiting, blurred vision, and papilledema.