ATI RN
Assess Vital Signs Questions
Question 1 of 5
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
Correct Answer: D
Rationale: The correct answer is D because ascites is fluid accumulation in the peritoneal cavity, causing a shifting dullness or fluid wave. Tympany that changes location with patient position (shifting dullness) is a classic finding in ascites, indicating the presence of fluid. Choices A, B, and C do not specifically indicate ascites. Bilateral flank tympany (choice A) is associated with bowel sounds, dullness that remains despite position change (choice B) may suggest a solid mass, and dullness centrally when supine (choice C) could be due to other abdominal organ enlargement.
Question 2 of 5
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway using which method?
Correct Answer: C
Rationale: The correct answer is C: Jaw thrust maneuver. This method is used to open the airway in a suspected cervical spine injury. Step 1: Place hands on either side of the patient's face, positioning the thumbs under the jaw. Step 2: Use the thumbs to gently lift the jaw forward, keeping the head in a neutral position. This technique helps maintain alignment of the cervical spine. The other choices are incorrect because A: Flexed position may worsen spinal injury, B: Head tilt-chin lift can cause further trauma in cervical spine injury, and D: Modified head tilt-chin lift is not recommended for suspected spinal injuries.
Question 3 of 5
The nurse is performing a head-to-toe assessment. Which sequence of assessment techniques is correct for the abdominal region?
Correct Answer: C
Rationale: The correct sequence for assessing the abdominal region is inspection, auscultation, percussion, palpation (Choice C). Inspection allows visual assessment for any abnormalities. Auscultation should be done before palpation to prevent altering bowel sounds. Percussion helps assess for organ size and density. Palpation is done last to assess for tenderness, masses, and organ shape. Explanation for why the other choices are incorrect: A: Incorrect because palpation should be done after auscultation. B: Incorrect because auscultation should be done before palpation. D: Incorrect because palpation should be the last step in the sequence.
Question 4 of 5
During a cardiovascular assessment, the nurse auscultates a murmur. How should the nurse describe this finding?
Correct Answer: D
Rationale: The correct answer is D because a murmur is described as a whooshing or swishing sound heard over the heart due to turbulent blood flow. This sound is typically heard during systole or diastole, which aligns with the timing of heart sounds. A: A palpable vibration is more characteristic of a thrill, not a murmur. B: An extra heart sound refers to S3 or S4, not a murmur. C: A high-pitched sound during inspiration is more indicative of wheezing in the lungs, not a murmur.
Question 5 of 5
The nurse is palpating lymph nodes during an assessment. Which characteristic of lymph nodes is concerning?
Correct Answer: D
Rationale: The correct answer is D: Hard and fixed. This characteristic is concerning as it may indicate malignancy or infection. Normal lymph nodes should be soft, mobile, and non-tender. Hard and fixed lymph nodes can be a sign of abnormal growth or metastasis. It is important to monitor such nodes closely and further investigate any concerning findings to rule out serious conditions. Choices A, B, and C describe normal characteristics of lymph nodes and are not typically concerning during assessment.