ATI RN
Vital Signs Assessment Nursing Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is performing a respiratory assessment and notes that the patient has a prolonged inspiratory phase. What condition is most likely associated with this finding?
Correct Answer: D
Rationale: The correct answer is D: Upper airway obstruction. A prolonged inspiratory phase suggests difficulty in inhaling, which is common in upper airway obstructions like a foreign body or swollen tissues. Asthma (A) typically presents with wheezing and expiratory phase prolongation. Pneumonia (B) is characterized by crackles and decreased breath sounds. Pulmonary edema (C) manifests as crackles and shortness of breath. Therefore, based on the prolonged inspiratory phase, the most likely condition is an upper airway obstruction.
Question 5 of 5
The colored probes of an electronic thermometer are indicative of:
Correct Answer: C
Rationale: Blue is for oral and red is for rectal, is correct based on common conventions in medical settings. Electronic thermometers often use color-coded probes to prevent cross-contamination: blue for oral use and red for rectal, reflecting their distinct anatomical applications. Blue and red are both for oral, ignores site-specific hygiene needs. Blue is for rectal and red is for oral, reverses the typical standard. Blue and red are both for rectal, disregards oral measurement needs. This color system aids quick identification, ensuring the oral probe isnt used rectally (risking infection) and vice versa. While manufacturer variations exist, C aligns with widespread nursing practice for clarity and safety, making it the correct answer.