ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse is assessing a patient's cranial nerve function and asks the patient to shrug both shoulders. Which cranial nerve is being tested?
Correct Answer: D
Rationale: The correct answer is D, Cranial nerve XI (spinal accessory nerve). This nerve controls the trapezius and sternocleidomastoid muscles, responsible for shoulder shrugging. Cranial nerve V (A) controls facial sensation and jaw movement. Cranial nerve VII (B) controls facial expression. Cranial nerve IX (C) controls swallowing and taste sensation. By process of elimination, D is the only nerve related to shoulder shrugging.
Question 2 of 5
The nurse is assessing a patient's abdomen and notes that the patient has ascites. What physical examination technique should the nurse use next?
Correct Answer: A
Rationale: The correct answer is A: Percussion for shifting dullness. Ascites is the accumulation of fluid in the peritoneal cavity leading to abdominal distension. By percussing the abdomen for shifting dullness, the nurse can identify fluid waves within the abdomen, confirming the presence of ascites. This technique helps differentiate ascites from other causes of abdominal distension. Auscultation for bowel sounds (B) is not directly related to assessing ascites. Palpation for tenderness (C) may be performed after confirming ascites to assess for underlying causes. Inspection for visible distension (D) can provide initial clues, but percussion for shifting dullness is needed for a definitive diagnosis of ascites.
Question 3 of 5
During a cardiovascular assessment, the nurse auscultates a split S2. What does this finding most likely indicate?
Correct Answer: A
Rationale: The split S2 sound is typically heard during inspiration and is considered a normal finding. It occurs due to a slight delay in the closure of the aortic valve compared to the pulmonic valve. This physiological delay results in the splitting of the S2 heart sound. Aortic stenosis (B), heart failure (C), and pulmonary embolism (D) are associated with different abnormal cardiovascular conditions that would present with other characteristic auscultatory findings, such as murmurs, gallops, or wheezing, respectively.
Question 4 of 5
The most appropriate definition of Vital Signs:
Correct Answer: B
Rationale: Vital signs are fundamental indicators used by healthcare professionals to assess the basic physiological functions of the body, such as temperature, pulse, respiration, and blood pressure. An indication of basic body functioning, accurately captures this concept because vital signs reflect how well the body is maintaining homeostasis and performing essential tasks like circulation and oxygenation. Signs and symptoms of a disease, is incorrect because vital signs are not exclusively tied to illness; they are monitored in healthy individuals too. A part of human composition, is vague and does not specify function, while Physiology and anatomy, refers to broader scientific fields rather than the specific measurements vital signs represent. Thus, B is the most precise and appropriate definition, aligning with clinical practice where vital signs serve as a baseline for evaluating health status.
Question 5 of 5
The primary source of heat in the body is:
Correct Answer: A
Rationale: produced as a byproduct of metabolic activities that generate energy for cellular functions, is correct as metabolism (e.g., in liver, muscles) generates heat via ATP production. No other choices are provided, but this aligns with physiology: cellular respiration converts nutrients into energy, releasing heat to maintain 98.6°F. Shivering or exercise boosts this, but basal metabolism is primary. The hypothalamus regulates this heat against losses (e.g., radiation). Unlike external sources, internal metabolic heat is constant, supporting homeostasis. Nursing recognizes this in fever (increased metabolism) or hypothermia (decreased). Thus, A is accurate, reflecting the bodys fundamental heat production mechanism.