ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The most common site of skeletal metastases is which of the following?
Correct Answer: A
Rationale: The correct answer is A: Axial skeleton. Skeletal metastases commonly occur in the axial skeleton due to its rich blood supply and high bone turnover rate. This makes it a favorable site for cancer cells to metastasize. Metastases in the femur, humerus, and radius are less common compared to the axial skeleton. The long bones like femur, humerus, and radius are more prone to primary bone tumors rather than metastases. Therefore, the correct answer is A as it aligns with the typical pattern of skeletal metastases.
Question 2 of 5
Which of the following is the most effective type of transcutaneous electrical nerve stimulation (TENS) stimulator?
Correct Answer: B
Rationale: The correct answer is B: High frequency, low intensity. This type of TENS stimulator is most effective because high frequency helps to block pain signals from reaching the brain, while low intensity ensures safety and prevents muscle contractions. High frequency stimulates nerve fibers that inhibit pain transmission, providing relief without causing discomfort. A: High frequency, high intensity can be too harsh and may lead to muscle contractions, causing discomfort. C: Low frequency, high intensity may not effectively block pain signals and can cause muscle contractions or discomfort. D: Low frequency, low intensity may not provide sufficient pain relief as it might not effectively block pain signals.
Question 3 of 5
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Correct Answer: B
Rationale: The correct answer is B. In this scenario, the nurse should prioritize immediate actions to ensure the patient's survival. By simultaneously asking history questions, performing the examination, and initiating life-saving measures, the nurse can quickly gather essential information while addressing the patient's critical needs. This approach allows for efficient data collection without compromising the patient's well-being. Choices A, C, and D are incorrect because they do not prioritize the patient's immediate needs. A delays life-saving measures by collecting history first, which can be detrimental in a critical situation. C focuses on detailed history information that is not essential for immediate care. D delays gathering any history information, which is crucial for understanding the patient's condition and providing appropriate care.
Question 4 of 5
A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely?
Correct Answer: D
Rationale: The correct answer is D: CN X lesion on the right. When the uvula deviates to the left upon touching the soft palate, it indicates a lesion of the right vagus nerve (CN X). The uvula is innervated by the vagus nerve, and when there is a lesion on the right side, the uvula will deviate away from the affected side due to the unopposed action of the intact left vagus nerve. Choices A and B are incorrect because cranial nerve IX (glossopharyngeal nerve) does not innervate the uvula. Choice C is incorrect as a lesion of the left vagus nerve would cause the uvula to deviate to the right, not the left.
Question 5 of 5
An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?
Correct Answer: C
Rationale: The correct answer is C: Ischemia. The elderly woman's history of coronary bypass surgery suggests a higher risk for vascular issues like mesenteric ischemia. The severe, diffuse abdominal pain that is not exacerbated by palpation is a classic presentation of mesenteric ischemia. This condition results from inadequate blood supply to the intestines and can lead to severe abdominal pain. Malingering (A) is unlikely as there is a legitimate medical history. Neuropathy (B) typically presents with different symptoms such as numbness or tingling rather than severe abdominal pain. Physical abuse (D) does not align with the clinical presentation and medical history.