ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Correct Answer: D
Rationale: The correct answer is D: Elevated pressure related to heart failure. The finding of jugular venous pulsations 5 cm above the sternal angle when the head of the bed is elevated 45 degrees is indicative of elevated central venous pressure, which is commonly seen in patients with heart failure. This is known as the hepatojugular reflux test, where pressure is transmitted back to the jugular veins due to increased right atrial pressure in heart failure. This finding suggests impaired cardiac function leading to fluid overload and congestion in the venous system. Choices A, B, and C are incorrect because they do not explain the specific pathophysiological mechanism associated with the patient's presentation.
Question 2 of 5
Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely?
Correct Answer: D
Rationale: The correct answer is D because the absence of symmetry of the inguinal areas with straining indicates a possible hernia. When Francis strains, if there is asymmetry in the inguinal areas, it suggests a weakness in the abdominal wall allowing for a hernia to protrude. This is a key sign of a hernia. A: Absence of pain with straining is not indicative of a hernia. Pain is often present in hernias. B: Absence of bowel sounds in the scrotum is not a typical sign of a hernia. Bowel sounds are usually heard in the abdomen. C: Absence of a varicocele refers to enlarged veins in the scrotum, which is unrelated to a hernia.
Question 3 of 5
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse.
Correct Answer: C
Rationale: The correct answer is C: Bounding. In hyperthyroidism, there is an excess of thyroid hormones which can lead to an increased heart rate and force of contraction. Bounding pulse refers to a strong and forceful pulse, which is expected in hyperthyroidism due to the increased cardiac output. Normal pulse (A) would not be expected as the heart rate is usually elevated in hyperthyroidism. Absent pulse (B) is not appropriate as hyperthyroidism typically leads to an increased pulse. Weak, thready pulse (D) is not expected as the increased cardiac output in hyperthyroidism usually results in a strong pulse.
Question 4 of 5
A 36-year-old female presents to the GP with painful hands which started two weeks ago. She describes the pain as constant but worst in the mornings where it takes an hour or so for her hands to loosen up and become fully functional. She has no significant past medical history and is functionally independent. On examination, there is erythema, swelling, and tenderness of the metacarpophalangeal joints on both hands. She is not able to make a tight fist due to the discomfort. On systemic examination, there is nothing else of note and vital signs are all within normal limits.
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. The key features suggesting rheumatoid arthritis in this case are the symmetrical involvement of the metacarpophalangeal joints, morning stiffness lasting more than an hour, and systemic symptoms such as erythema and swelling. Rheumatoid arthritis is an autoimmune condition that typically presents with these symptoms. Choice A: Gout typically presents with sudden onset of severe pain, redness, and swelling in a single joint, commonly the big toe. It is unlikely in this case due to the symmetrical joint involvement. Choice C: Osteoarthritis is characterized by joint pain that worsens with activity and improves with rest. It usually affects weight-bearing joints like the knees and hips, not typically presenting with the described symptoms in the hands. Choice D: Septic arthritis often presents with acute joint pain, fever, and systemic symptoms. It is less likely in this case as the patient does not have signs of systemic infection.
Question 5 of 5
You ask a patient to draw a clock. He fills in all the numbers on the right half of the circle. What do you suspect?
Correct Answer: A
Rationale: The correct answer is A: Hemianopsia. This is because filling only the numbers on the right half of the clock suggests a visual field defect on the left side, a common symptom of hemianopsia. This could indicate damage to the brain's visual processing areas, such as in stroke or brain injury. Fatigue (B), Oppositional defiant disorder (C), and Depression (D) are unlikely to cause this specific symptom and should be ruled out through further assessment.