ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During a physical assessment, the nurse observes that the patient has a positive Homan's sign. What condition does this finding suggest?
Correct Answer: A
Rationale: The positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which is a classic sign of deep vein thrombosis (DVT). This occurs due to blood clot formation in the deep veins of the lower extremities, leading to calf pain with movement. Peripheral artery disease (B) presents with symptoms of intermittent claudication, not calf pain with dorsiflexion. Venous insufficiency (C) causes swelling and skin changes, not specifically calf pain with dorsiflexion. Pulmonary embolism (D) presents with symptoms like chest pain, shortness of breath, and cough, not calf pain with dorsiflexion.
Question 2 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 3 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 4 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.
Question 5 of 5
Core temperatures are not measured at:
Correct Answer: D
Rationale: Sublingual site, is correct because it measures oral temperature, considered a surface reading, not a true core site. Core temperature reflects internal body heat (e.g., 98.6°F-100.4°F) and is taken at sites like Tympanic site (ear, near hypothalamus), Rectal site (most accurate), and Bladder (via catheter). Sublingual (under tongue) readings, while reliable, are slightly lower (~98.6°F) and influenced by air or food, making them non-core. Nursing distinguishes core for critical monitoring (e.g., hypothermia) versus surface for routine checks. Thus, D is the accurate choice, aligning with thermometry standards and physiological definitions.