ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is assessing a patient's abdomen and notices rebound tenderness. What condition does this finding suggest?
Correct Answer: B
Rationale: Rebound tenderness, where pain worsens upon releasing pressure, is a sign of peritonitis, inflammation of the abdominal lining. This suggests an urgent medical issue involving the peritoneum. Cholecystitis (A) is inflammation of the gallbladder, not the peritoneum. Appendicitis (C) involves the appendix, not the peritoneum. Diverticulitis (D) is inflammation of diverticula in the colon, not the peritoneum. Peritonitis is the correct answer due to the specific association of rebound tenderness with peritoneal inflammation.
Question 2 of 5
The nurse is performing an abdominal assessment and notes that the patient has rebound tenderness. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Rebound tenderness is indicative of peritonitis, an inflammation of the peritoneum. Appendicitis, which involves inflammation of the appendix, commonly leads to peritonitis due to perforation. Therefore, the correct answer is A: Appendicitis. Cholecystitis (B), pancreatitis (C), and diverticulitis (D) do not typically cause peritonitis and rebound tenderness.
Question 3 of 5
During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Palpation with deep pressure on the right upper quadrant. This technique is appropriate because the liver is located in the right upper quadrant of the abdomen, and palpation with deep pressure allows the nurse to feel for any enlargement or abnormalities. Percussion (Choice A) is used to identify organ borders, not necessarily to assess for enlargement. Auscultation for liver bruits (Choice C) is not typically done during a routine abdominal examination for liver enlargement. Inspection for visible pulsations (Choice D) is more indicative of an abdominal aortic aneurysm, not liver enlargement.
Question 4 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.
Question 5 of 5
The most appropriate position in obtaining a rectal temperature for an adult would be:
Correct Answer: C
Rationale: Sims, is correct because the Sims position (left lateral with upper leg flexed) provides optimal access to the rectum for temperature measurement in adults. It ensures patient comfort and safety while allowing the nurse to insert the probe accurately. Supine (lying flat on back), is impractical for rectal access. Fowlers (semi-sitting), is used for respiratory ease, not rectal procedures. Lateral (side-lying), is close but less specific than Sims, which includes leg positioning for better exposure. Rectal temperature, a core measurement, requires proper positioning to avoid discomfort or injury, and Sims is standard in clinical practice for its anatomical alignment, making C the most appropriate choice.