ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is assessing a patient for signs of deep vein thrombosis (DVT). Which finding is most indicative of DVT?
Correct Answer: B
Rationale: The correct answer is B: Unilateral leg swelling and warmth. This finding is most indicative of DVT because it is a classic symptom, suggesting a blood clot in a deep vein. Unilateral leg swelling and warmth are commonly associated with DVT due to impaired blood flow. Cool, pale skin (A) is not specific to DVT. Bilateral leg edema (C) is more suggestive of heart failure or venous insufficiency. Weak pulses in both legs (D) are not typical of DVT and may indicate peripheral arterial disease. Unilateral leg swelling and warmth in the context of DVT assessment should prompt further investigation and intervention.
Question 2 of 5
Which of the following techniques is most appropriate for assessing thyroid gland enlargement?
Correct Answer: B
Rationale: The correct answer is B: Palpation while the patient swallows. This technique is most appropriate for assessing thyroid gland enlargement because it allows the healthcare provider to feel for any abnormal swelling or nodules in the thyroid gland as the patient swallows. Percussion of the thyroid gland (A) is not commonly used for assessing thyroid gland enlargement. Auscultation for bruits over the thyroid gland (C) is more relevant for detecting abnormal blood flow and is not typically used as a primary method for assessing enlargement. Inspection of the neck veins (D) is unrelated to assessing thyroid gland enlargement.
Question 3 of 5
The nurse is assessing a patient's capillary refill time. What is the normal finding for this assessment?
Correct Answer: B
Rationale: The correct answer is B: Less than 2 seconds. Capillary refill time measures the time it takes for blood to return to the capillaries after pressure is applied and released. A normal finding is less than 2 seconds, indicating adequate peripheral perfusion. Choices A, C, and D are incorrect as they exceed the normal capillary refill time, which could suggest inadequate circulation and potential perfusion issues. Choice A (<1 second) may indicate hypervolemia or vasodilation, while choices C (>3 seconds) and D (>4 seconds) may indicate hypovolemia or vasoconstriction, respectively. Hence, the correct answer is less than 2 seconds, as it indicates normal capillary refill time and adequate blood flow.
Question 4 of 5
During a skin assessment, the nurse notes that the patient has petechiae. What is the primary cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Capillary bleeding. Petechiae are tiny, pinpoint, round spots that appear on the skin due to bleeding under the skin. This is caused by capillaries leaking blood into the skin, leading to the characteristic appearance of petechiae. Dilated capillaries (A) do not directly cause petechiae. Increased melanin production (C) results in skin pigmentation changes, not petechiae. Loss of collagen (D) may lead to skin changes like sagging, but it is not the primary cause of petechiae.
Question 5 of 5
During a cardiac assessment, the nurse notes a high-pitched, scratchy sound heard during both systole and diastole. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Pericardial friction rub, as it is a high-pitched, scratchy sound heard during both systole and diastole, indicating inflammation of the pericardium. This sound is produced by the rubbing of inflamed pericardial layers during the cardiac cycle. B: Aortic stenosis produces a systolic murmur. C: Mitral valve regurgitation produces a holosystolic murmur. D: Heart murmur is a generic term and does not specifically describe the high-pitched, scratchy sound heard during both systole and diastole.