ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because watching the patient's respirations while listening for the effect on the sound can help differentiate between an S3 and an opening snap or ejection sound. Observing how the sound changes with the respiratory cycle can provide valuable information about the origin and nature of the sound. Choice A is incorrect because having the patient turn to the left side with the bell of the stethoscope is typically done to enhance the detection of a mitral murmur, not to assess a sound immediately after S2. Choice B is incorrect because asking the patient to hold their breath is more relevant in assessing for a pericardial friction rub, not in differentiating between heart sounds. Choice C is incorrect because assuming the sound is an S3 without further assessment can lead to a misdiagnosis. It is essential to confirm the nature of the sound through appropriate assessment techniques.
Question 2 of 5
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
Correct Answer: A
Rationale: The correct answer is A: Claudication. This patient is likely experiencing intermittent claudication, which is pain or discomfort in the muscles of the leg, typically the calf, that occurs during physical activity and is relieved by rest. The key clues in the question are the pain in the left calf specifically with activity (climbing stairs), relief with rest, and the patient's age of 67 which is a risk factor for peripheral artery disease (PAD) leading to claudication. Sore muscles (B) and muscle cramps (C) do not typically present with this pattern of pain and relief. Venous insufficiency (D) usually manifests with swelling, skin changes, and may worsen with prolonged standing, not specifically with activity like in this case.
Question 3 of 5
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
Correct Answer: B
Rationale: The correct answer is B: Raynaud disease. This condition is characterized by a triphasic color change in the fingers (white, blue, red) due to vasospasms in response to cold or stress. The white color indicates decreased blood flow, the blue color is due to lack of oxygen, and the red color signifies reactive hyperemia. The burning, throbbing pain is also a common symptom. Lymphedema (A) is swelling due to lymphatic system dysfunction, not color changes. Deep-vein thrombosis (C) involves blood clots in the deep veins, not color changes. Chronic arterial insufficiency (D) would typically present with a pale or dusky color due to reduced blood flow, rather than the described color changes.
Question 4 of 5
Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?
Correct Answer: A
Rationale: The correct answer is A: You diagnose "white coat hypertension." White coat hypertension refers to elevated blood pressure readings in a clinical setting due to anxiety or stress. Mr. Kelly's lower readings at home suggest this phenomenon. 1. White coat hypertension is a common occurrence, affecting about 20% of people with high office BP readings. 2. Mr. Kelly's consistent lower readings at home indicate that his true BP is likely lower than what is measured in the office. 3. Checking BP at home twice a day at the same time increases reliability and accuracy. 4. Assuming nervousness or questioning the accuracy of his measurements or yours does not address the discrepancy between office and home readings.
Question 5 of 5
You completed the health history and physical examination on your new admission. After completing the assessment phase of the nursing process, the next step includes which of the following?
Correct Answer: A
Rationale: The correct answer is A: Interpreting clinical findings and determining a diagnosis. This step follows the assessment phase of the nursing process. First, you collect data during the assessment phase. Next, you interpret the data to make a diagnosis. This involves analyzing the clinical findings and determining the patient's health status. Choice B is incorrect because clustering cues and evaluating assessment data are part of the assessment phase, not the next step. Choice C is incorrect as collaborating with the patient and reviewing information is important but typically occurs earlier in the process. Choice D is incorrect as evaluating the information collected is part of the assessment phase, not the next step.