ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
Correct Answer: C
Rationale: The correct answer is C: Displacement of the heart from elevation of the diaphragm. During pregnancy, the growing uterus pushes the diaphragm upwards, causing the heart to be displaced upwards and laterally. This displacement results in the apical impulse being palpated at a higher position, such as the fourth left intercostal space lateral to the midclavicular line. This finding is a normal physiological change due to pregnancy and does not indicate any cardiac pathology. Explanation of other choices: A: Right ventricular hypertrophy - This is unlikely in a pregnant patient without underlying cardiac conditions. B: Increased volume and size of the heart as a result of pregnancy - While the heart may undergo some changes during pregnancy, palpating the apical impulse at a higher position is specifically due to displacement of the heart by the elevated diaphragm, not increased heart size. D: Increased blood flow through the internal mammary artery - This choice is unrelated to the displacement of the heart and the
Question 2 of 5
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 5 seconds in an adult is considered delayed and may indicate poor perfusion or circulatory issues. The nurse should investigate further to determine the underlying cause. Option A is incorrect as frostbite history does not directly relate to the capillary refill time in this scenario. Option B is incorrect as venous insufficiency does not typically affect capillary refill time. Option D is incorrect because a capillary refill time of 5 seconds is not considered normal in adults and warrants further evaluation.
Question 3 of 5
A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom?
Correct Answer: C
Rationale: The correct answer is C: Cardiac. Shortness of breath is a common symptom of cardiac conditions such as heart failure or coronary artery disease. The heart plays a crucial role in pumping oxygenated blood to the body, so any dysfunction can lead to inadequate oxygen supply and result in shortness of breath. Reproductive (A), urinary (B), and hematologic (D) systems are not primarily responsible for regulating oxygen supply and are unlikely to directly cause shortness of breath.
Question 4 of 5
A 26-year-old violinist comes to your clinic, complaining of anxiety. He is a first chair violinist in the local symphony orchestra and has started having symptoms during performances, such as sweating, shaking, and hyperventilating. It has gotten so bad that he has thought about giving up his first chair status so he does not have to play the solo during one of the movements. He says that he never has these symptoms during rehearsals or when he is practicing. He denies having any of these symptoms at any other time. His past medical history is unremarkable. He denies any tobacco use, drug use, or alcohol abuse. His parents are both healthy. On examination you see a young man who appears worried. His vital signs and physical examination are unremarkable. What type of anxiety disorder best describes his situation?
Correct Answer: C
Rationale: The correct answer is C: Social phobia. The patient's symptoms of anxiety specifically occur in performance situations, such as playing solos with the orchestra, but not during rehearsals or practice sessions. This is characteristic of social phobia, also known as social anxiety disorder. Social phobia involves intense fear or anxiety about social situations where the individual may be scrutinized or judged, leading to avoidance of those situations. In this case, the patient's fear and anxiety are triggered by performing in front of an audience, which aligns with the diagnosis of social phobia. Choice A, Panic disorder, is incorrect because the patient's symptoms are specifically related to performance situations and not sudden, unexpected panic attacks. Choice B, Specific phobia, is incorrect because the fear is not related to a specific object or situation but rather to performing in front of others. Choice D, Generalized anxiety disorder, is incorrect because the patient's anxiety is not pervasive across various aspects of his life but is focused on
Question 5 of 5
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. c. Lives alone, no family in the area
Correct Answer: C
Rationale: The correct answer is C: Third-level. The patient's presentation suggests he may be experiencing a cardiac event requiring immediate attention (first-level). The fact that he lives alone with no family in the area is a social issue (third-level) that could impact his ability to receive necessary ongoing care and support post-discharge, but it does not pose an immediate threat to his life. Therefore, addressing his immediate medical needs takes precedence over this social issue. Choices A and B are incorrect as they do not accurately reflect the urgency and priority level of the patient's problems.