ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
During a neurological assessment, the nurse observes that the patient has difficulty walking on their toes. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar ataxia. Difficulty walking on toes is a sign of cerebellar dysfunction, affecting coordination and balance. The cerebellum plays a crucial role in coordinating voluntary movements, including maintaining balance and posture. In cerebellar ataxia, there is a lack of coordination in muscle movements, leading to difficulties in performing fine motor tasks like walking on toes. Peripheral neuropathy (B) primarily affects sensory and motor nerves in the limbs, causing tingling, numbness, and weakness, not specifically difficulty in walking on toes. Parkinson's disease (C) is characterized by tremors, rigidity, and bradykinesia but typically does not present with difficulty walking on toes. Stroke (D) can cause motor deficits but typically does not manifest as isolated difficulty walking on toes.
Question 2 of 5
The nurse is performing a cardiovascular assessment and auscultates a grade 3/6 murmur at the left lower sternal border. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Document the murmur and report it to the physician. A grade 3/6 murmur is moderate in intensity and may indicate a significant underlying heart condition. By documenting and reporting it to the physician promptly, the nurse ensures timely evaluation and appropriate management. Reassessing the murmur in 30 minutes (choice A) may delay necessary intervention. Performing a complete physical examination to rule out other cardiac abnormalities (choice C) is important but may not be immediately necessary for addressing the murmur. Initiating cardiac monitoring immediately (choice D) is not the priority in this scenario; informing the physician for further evaluation is more crucial.
Question 3 of 5
The nurse is assessing a patient's abdomen and notes that the patient has a firm, non-tender mass. What is the next step in the assessment?
Correct Answer: D
Rationale: The correct answer is D: Refer the patient for imaging. When a nurse encounters a firm, non-tender mass in the abdomen, it is important to proceed with imaging to determine the nature of the mass. Imaging studies such as ultrasound, CT scan, or MRI can provide valuable information about the size, location, and characteristics of the mass. This step is crucial in identifying the potential underlying causes of the mass, such as tumors, cysts, or other abnormalities. Option A is incorrect because percussion is not typically used to assess for fluid in a mass. Option B is incorrect as palpation may not be safe if the mass is suspected to be malignant. Option C is incorrect as auscultation for bowel sounds may not provide relevant information about the mass. The best course of action is to refer the patient for imaging to further evaluate the mass accurately.
Question 4 of 5
The nurse is performing an abdominal assessment and detects a pulsatile mass in the midline of the abdomen. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Abdominal aortic aneurysm. The detection of a pulsatile mass in the midline of the abdomen is highly indicative of an abdominal aortic aneurysm. This is because the aorta runs in the midline of the abdomen, and an aneurysm in this area can present as a pulsatile mass. An abdominal aortic aneurysm is a serious condition that requires immediate medical attention. Choices B, C, and D are incorrect because cholecystitis, pancreatitis, and gastritis do not typically present with a pulsatile mass in the midline of the abdomen.
Question 5 of 5
The nurse is assessing a patient's heart sounds and notes that the patient has a S3 heart sound. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. An S3 heart sound is often indicative of volume overload and impaired ventricular function, both of which are common in heart failure. The S3 sound occurs in early diastole when the ventricle is rapidly filling. In contrast, choices B, C, and D are not typically associated with S3 heart sounds. Mitral valve regurgitation causes a murmur, aortic stenosis causes a systolic murmur, and pulmonary embolism does not typically produce S3 heart sounds.