ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
During a pain assessment, the patient rates their pain as 8 on a scale of 0 to 10. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Administer prescribed pain medication. The priority action is to address the patient's pain to provide relief and improve comfort. Administering pain medication is essential to manage the patient's pain effectively. Reassessing the pain in 30 minutes (choice A) delays pain relief. Simply documenting the pain level as reported (choice C) without taking action does not address the patient's immediate needs. Applying a warm compress (choice D) may provide some comfort but does not directly address the pain intensity reported by the patient. Administering pain medication is the most appropriate and immediate action to address the patient's discomfort.
Question 2 of 5
During a respiratory assessment, the nurse notes that the patient is using their accessory muscles to breathe. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Acute asthma exacerbation. When a patient is using accessory muscles to breathe, it indicates respiratory distress. In acute asthma exacerbation, airway constriction leads to difficulty breathing, causing the patient to use accessory muscles to aid in breathing. This is a characteristic feature of asthma exacerbation. Summary: - B: COPD is characterized by chronic airflow limitation, not typically associated with sudden use of accessory muscles. - C: Pneumothorax is a collapsed lung, which may cause shortness of breath but doesn't usually result in the use of accessory muscles. - D: Pulmonary embolism is a blockage in a pulmonary artery, which can lead to shortness of breath but doesn't typically cause the use of accessory muscles for breathing.
Question 3 of 5
During a neurological assessment, the nurse asks the patient to close their eyes and identify familiar objects. Which sensory function is being tested?
Correct Answer: D
Rationale: The correct answer is D: Stereognosis. This test assesses the patient's ability to identify familiar objects through touch and manipulation without visual cues. It specifically evaluates the integration of tactile, proprioceptive, and sensorimotor functions in the brain. The other options are incorrect because: A: Pain sensation is typically assessed using a pinprick test. B: Proprioception is evaluated through tests involving joint position sense and movement. C: Light touch sensation is tested by using a cotton wisp or a gentle touch stimulus.
Question 4 of 5
During a respiratory assessment, the nurse notes that the patient has a prolonged inspiratory phase. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Upper airway obstruction. A prolonged inspiratory phase suggests resistance to airflow during inhalation, which is characteristic of upper airway obstruction. This could be due to a blockage in the upper airway, such as by a foreign body or swelling. Asthma (A) and COPD (B) typically present with expiratory phase abnormalities, not prolonged inspiratory phase. Pneumonia (D) may cause crackles and decreased breath sounds, but not specifically a prolonged inspiratory phase.
Question 5 of 5
A 50-year-old man presents with shortness of breath, a cough, and a history of smoking. He has a barrel-shaped chest and wheezing on auscultation. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's age, smoking history, barrel-shaped chest, wheezing, and chronic symptoms are indicative of COPD. COPD is a chronic lung condition characterized by airflow obstruction and difficulty breathing. Pneumonia (A) typically presents with acute symptoms like fever and productive cough, not chronic symptoms. Asthma (C) usually presents with episodic symptoms and may have a different pattern of wheezing. Pulmonary embolism (D) presents with acute onset of shortness of breath and chest pain, not chronic symptoms like in this case.