ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D because in children, the sound produced by percussing over the lungs can sometimes be louder, longer, and lower in pitch compared to adults due to their thinner chest walls. This finding is considered normal for a child of this age and should not raise concerns. Palpating for pain or tenderness (Choice A) is not necessary as the loud tones are not indicative of pathology. Asking the child to take shallow breaths (Choice B) would not change the percussion findings. Referring the child immediately (Choice C) is unwarranted as the findings are within the expected range for a 4-year-old.
Question 2 of 5
The nurse is conducting a respiratory assessment. Which finding requires immediate attention?
Correct Answer: D
Rationale: The correct answer is D: Use of accessory muscles during breathing. This finding indicates respiratory distress and requires immediate attention as it suggests the patient is having difficulty breathing effectively. Accessory muscle use signifies increased work of breathing and potential respiratory compromise. A: A respiratory rate of 16 breaths per minute is within the normal range. B: An SpO2 of 92% on room air is slightly below the normal range but may not require immediate intervention. C: Bilateral lung sounds clear to auscultation indicate normal breath sounds and do not suggest imminent respiratory distress.
Question 3 of 5
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Correct Answer: D
Rationale: The correct answer is D: Midbrain. Decerebrate posturing is a specific type of abnormal posturing that indicates damage to the midbrain. In decerebrate posturing, the arms are extended and pronated, and the legs are extended with plantar flexion. This posture is a result of the disruption of the neural pathways between the brain and spinal cord that pass through the midbrain. Damage to the cortex (choice A) would not result in decerebrate posturing. The diencephalon (choice B) is responsible for regulating many important functions, but it does not directly control motor responses like posturing. The medulla (choice C) is primarily involved in regulating vital functions like breathing and heart rate, not motor posturing. Therefore, the correct answer is D, midbrain, as damage to this area leads to decerebrate posturing.
Question 4 of 5
A physical therapist completes an examination on a five-year-old boy diagnosed with Duchenne muscular dystrophy. The referral indicates that the boy was diagnosed with the disease less than one year ago. Assuming a normal progression, which of the following would be expected?
Correct Answer: B
Rationale: The correct answer is B: Proximal muscle weakness. In Duchenne muscular dystrophy, proximal muscle weakness is typically one of the earliest signs due to the progressive degeneration of muscle fibers. This weakness starts in the pelvic girdle and lower extremities before affecting the upper extremities. Distal muscle weakness (choice A) occurs later in the disease progression. Impaired respiratory function (choice C) is also a common feature in Duchenne muscular dystrophy but usually develops later in the disease course. Inability to perform activities of daily living (choice D) may occur eventually, but proximal muscle weakness is the more immediate and expected outcome in a newly diagnosed five-year-old with Duchenne muscular dystrophy.
Question 5 of 5
A physical therapist observes a patient completing a treadmill exercise test. The patient's blood pressure rises significantly during exercise. The therapist should recognize this as:
Correct Answer: A
Rationale: The correct answer is A: A normal response to exercise. During exercise, it is common for blood pressure to increase as the body works harder to supply oxygen to the muscles. This is known as the exercise pressor response and is a normal physiological reaction to physical activity. It helps the body meet the increased demand for oxygen during exercise. Choices B, C, and D are incorrect because a rise in blood pressure during exercise is generally expected and not necessarily indicative of an issue that requires test termination, poor cardiovascular fitness, or a contraindication to exercise.