ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?
Correct Answer: A
Rationale: The correct answer is A because placing the client on the back with a small pillow under the head can increase the risk of aspiration for stroke patients. The rationale is that this position can cause the tongue to obstruct the airway, leading to difficulty swallowing and potentially causing aspiration pneumonia. B: Keeping portable suctioning equipment at the bedside is important for immediate intervention in case of oral secretions or choking. C: Opening the client's mouth with a padded tongue blade can help provide better access for oral hygiene procedures. D: Cleaning the client's mouth and teeth with a toothbrush is a crucial nursing measure to prevent oral health issues and maintain overall hygiene.
Question 2 of 5
A physical therapist examines the lymph nodes of a 62-year-old male diagnosed with lymphoma. Which of the following is the therapist MOST likely to observe?
Correct Answer: C
Rationale: The correct answer is C: Hard, nontender, and immobile lymph nodes. In lymphoma, lymph nodes often become enlarged due to cancerous cell growth, leading to hard consistency. The lack of tenderness is typical in lymphoma, unlike infections. Immobility indicates infiltration of cancer cells disrupting normal node movement. Choices A, B, and D are incorrect as they do not align with the typical characteristics of lymphoma presentation, which involves hard, nontender, and immobile lymph nodes.
Question 3 of 5
A physical therapist prepares to perform manual muscle testing on a patient with suspected quadriceps weakness. Which patient position would BEST isolate this muscle group?
Correct Answer: D
Rationale: The correct answer is D, sitting. Sitting position isolates quadriceps as it eliminates involvement of other muscle groups. In sitting, gravity minimally affects the quadriceps, allowing for accurate testing. Side-lying (A) engages hip abductors, supine (B) involves hip flexors, and prone (C) activates hip extensors, interfering with accurate quadriceps testing.
Question 4 of 5
A patient recovering from a stroke demonstrates neglect on the left side. Which intervention is MOST appropriate to address this deficit?
Correct Answer: B
Rationale: The correct answer is B: Encourage scanning to the left side. This intervention is appropriate because it helps the patient actively engage in exploring their neglected side, promoting awareness and attention to that side. By encouraging scanning to the left, the patient can improve their ability to attend to and interact with stimuli on the neglected side. A: Position objects on the unaffected side does not actively engage the patient in addressing the neglect on the left side. C: Providing verbal cues to the right side may not effectively stimulate the neglected side and may not promote active engagement. D: Focusing therapy on the unaffected side does not directly address the neglect on the left side and may not lead to improvement in neglect symptoms.
Question 5 of 5
The nurse is assessing a patient with suspected deep vein thrombosis (DVT). Which test is most useful for confirming this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: D-dimer test. The D-dimer test is a blood test that measures the presence of a substance released when a blood clot dissolves. In patients with suspected DVT, an elevated D-dimer level suggests the presence of a blood clot. This test is non-invasive, easy to perform, and can help confirm the diagnosis of DVT. A: Homan's sign is not a reliable test for DVT as it lacks specificity and sensitivity. C: Ankle-brachial index is used to assess peripheral arterial disease, not DVT. D: Chest X-ray is not useful for diagnosing DVT as it primarily shows lung and heart abnormalities.