ATI RN
Vital Signs Assessment Questions
Question 1 of 5
During a skin assessment, the nurse notes a lesion with irregular borders and varied colors. What is the next action?
Correct Answer: B
Rationale: The correct answer is B: Refer the patient for further evaluation. This is because the lesion with irregular borders and varied colors raises concern for possible skin cancer. Referring the patient for further evaluation by a dermatologist is crucial to determine the nature of the lesion and initiate appropriate treatment. Documenting it as a normal finding (choice A) is incorrect as it may delay necessary intervention. Applying an antibiotic ointment (choice C) is not indicated as the lesion is not suggestive of infection. Reassessing the lesion in one month (choice D) could lead to a delay in diagnosis and treatment if the lesion is indeed malignant.
Question 2 of 5
The nurse is conducting a pain assessment. Which question best evaluates the quality of the patient's pain?
Correct Answer: B
Rationale: The correct answer is B: What does the pain feel like? This question is best for evaluating the quality of pain because it helps determine the characteristics and nature of the pain, such as sharp, dull, throbbing, burning, etc. Understanding the specific qualities of pain can provide valuable insights into possible causes and appropriate interventions. A: When did the pain start? This question assesses the onset of pain, not its quality. C: What makes the pain better or worse? This question evaluates exacerbating or alleviating factors, not the quality of pain. D: Where is the pain located? This question assesses the location of pain, not its quality.
Question 3 of 5
The nurse is auscultating heart sounds and notes a split S2 during inspiration. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. During inspiration, the intrathoracic pressure decreases, causing the pulmonary artery to fill more slowly than the aorta, resulting in a split S2. This is a physiological phenomenon known as a respiratory split, which is considered normal. Choices B, C, and D are incorrect because they do not correlate with the specific finding of a split S2 during inspiration. Mitral valve regurgitation and aortic stenosis typically present with different auscultatory findings, while heart failure may manifest with additional signs and symptoms beyond just a split S2.
Question 4 of 5
The following information is best placed in which category? 'The patient had a stent placed in the left anterior descending artery (LAD) in 1999.'
Correct Answer: A
Rationale: The correct answer is A: Adult illnesses. The information about a stent placed in an artery relates to a medical procedure for a cardiovascular condition, which falls under adult illnesses. This category encompasses conditions and treatments related to the health of adults. Surgeries (B) would be too broad and not specific to the medical context provided. Obstetrics/gynecology (C) focuses on women's reproductive health and pregnancy-related issues, which are not relevant here. Psychiatric (D) pertains to mental health and psychological disorders, which is also not applicable to the given information.
Question 5 of 5
The nurse is performing a neurological assessment and notes a positive Romberg test. What does this finding indicate?
Correct Answer: B
Rationale: The Romberg test assesses balance and postural stability. A positive Romberg test indicates a deficit in proprioception, which is commonly seen in cerebellar ataxia or vestibular dysfunction. The cerebellum and vestibular system play crucial roles in maintaining balance and coordination. Cranial nerve dysfunction (A) does not directly affect balance. Peripheral neuropathy (C) primarily affects sensation and motor function, not balance. Increased intracranial pressure (D) may present with other neurological signs, but not specifically a positive Romberg test. Therefore, the correct answer is B.