ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). Which score indicates a moderate head injury?
Correct Answer: B
Rationale: The correct answer is B (9-12) because a GCS score of 9-12 indicates a moderate head injury. This score reflects a patient who is moderately impaired in terms of consciousness and neurological functioning. A GCS score of 13-15 (choice A) indicates mild injury, while a score of 6-8 (choice C) indicates severe injury. A score of 3-5 (choice D) indicates a critical and severe head injury, typically associated with deep coma. In summary, the GCS score of 9-12 represents a moderate head injury, while the other choices reflect different levels of severity in head injuries based on the Glasgow Coma Scale.
Question 2 of 5
The nurse is performing a physical assessment and notes that the patient has unilateral leg swelling. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). Unilateral leg swelling is a common symptom of DVT, which is a blood clot in the deep veins of the leg. The swelling occurs due to impaired blood flow caused by the clot. It is important to consider DVT as it can lead to serious complications like pulmonary embolism. Incorrect choices: B: Congestive heart failure typically presents with bilateral leg swelling due to fluid retention. C: Peripheral artery disease usually manifests with symptoms like leg pain while walking, not necessarily swelling. D: Chronic venous insufficiency results in long-standing venous hypertension leading to skin changes like ulcers, not acute unilateral swelling.
Question 3 of 5
The nurse is performing a neurological assessment and asks the patient to squeeze their hands. Which of the following is being tested?
Correct Answer: B
Rationale: The correct answer is B: Motor function and strength. When the nurse asks the patient to squeeze their hands, they are assessing the patient's ability to generate force through muscle contractions, which tests motor function and strength. This action primarily involves the upper extremity muscles and requires intact nerve pathways from the brain to the muscles. Incorrect Choices: A: Cerebellar function is responsible for coordination, balance, and muscle tone, not squeezing hands. C: Sensory function involves detecting stimuli like touch, pain, temperature, and vibration, which are not directly tested by squeezing hands. D: Coordination is tested through tasks requiring precise movements and smooth performance, such as finger-to-nose or heel-to-shin tests, not squeezing hands.
Question 4 of 5
A 60-year-old woman presents with a complaint of joint pain, particularly in the knees. She reports that the pain is worse with activity and improves with rest. She has a history of obesity. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for the 60-year-old woman with joint pain worsened by activity and improved with rest, along with a history of obesity, is osteoarthritis (OA). OA is the most common type of arthritis in older individuals, often affecting weight-bearing joints like the knees. The pain pattern described aligns with OA, as it typically worsens with activity due to the degeneration of cartilage and improves with rest. Rheumatoid arthritis (B) is less likely as it typically presents with symmetrical joint involvement and morning stiffness. Gout (C) is characterized by sudden, severe attacks of pain in joints due to the buildup of uric acid crystals and is less likely based on the provided information. Psoriatic arthritis (D) is associated with psoriasis skin lesions, which are not mentioned in the scenario, making it less likely.
Question 5 of 5
During a neurological assessment, the nurse asks the patient to touch their nose with their finger and then touch the nurse's finger. Which function is being assessed?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar function and coordination. This test, known as the finger-to-nose test, assesses the coordination and fine motor skills controlled by the cerebellum. The patient's ability to accurately touch their nose and the nurse's finger evaluates the cerebellar function. Choice B (Cranial nerve function) is incorrect because this test primarily assesses motor coordination rather than cranial nerve function. Choice C (Proprioception) is incorrect as proprioception evaluates the awareness of body position, not coordination. Choice D (Memory) is incorrect as the finger-to-nose test does not assess memory but rather motor function.