ATI RN
Vital Signs Assessment Nursing Questions
Question 1 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 2 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 3 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.
Question 4 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the shoulder. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Frozen shoulder (adhesive capsulitis). Frozen shoulder is characterized by pain and stiffness in the shoulder joint, leading to limited range of motion. The condition typically progresses through three stages: freezing, frozen, and thawing. During the freezing stage, inflammation and scarring of the shoulder capsule cause pain and restricted movement. In contrast, osteoarthritis primarily affects the joints, causing pain, stiffness, and reduced range of motion over time. Rheumatoid arthritis is a systemic autoimmune condition that can cause joint inflammation, but it usually affects multiple joints symmetrically. Bursitis involves inflammation of the bursae, fluid-filled sacs that cushion the joints, leading to pain and swelling but not necessarily restricted range of motion in the shoulder.
Question 5 of 5
The nurse is performing a cranial nerve assessment and asks the patient to follow a moving target with their eyes. Which cranial nerve is being tested?
Correct Answer: B
Rationale: The correct answer is B: Cranial nerve III (oculomotor nerve). This nerve controls most eye movements, including tracking a moving target. Cranial nerve II (optic nerve) is responsible for vision, not eye movements. Cranial nerve IV (trochlear nerve) controls downward and inward eye movements, not tracking. Cranial nerve VI (abducens nerve) controls lateral eye movements, not tracking. Therefore, the oculomotor nerve is specifically being tested in this scenario.