ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's lungs and notes that the patient has a dull percussion note over the left lower lung field. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The dull percussion note indicates fluid accumulation in the lung field, typical of pleural effusion. This fluid-filled space dampens sound transmission, resulting in a dull sound. This finding is consistent with pleural effusion, making choice B the correct answer. Normal lung tissue (Choice A) would produce a resonant percussion note. Pneumothorax (Choice C) would typically produce hyperresonant or tympanic sounds. Bronchitis (Choice D) affects airways and does not directly impact percussion notes.
Question 2 of 5
During a respiratory assessment, the nurse observes that the patient has bilateral crackles on inspiration. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The presence of bilateral crackles on inspiration suggests fluid in the lungs, which is characteristic of pulmonary edema. Pulmonary fibrosis is associated with fine, late inspiratory crackles. Pneumonia typically presents with focal crackles in the affected area. Asthma is characterized by wheezing rather than crackles. Therefore, the correct answer is B as it aligns with the clinical presentation of bilateral crackles on inspiration in pulmonary edema.
Question 3 of 5
The nurse is performing a cardiovascular assessment and notes that the patient has a bounding pulse. What condition is most likely associated with this finding?
Correct Answer: B
Rationale: The correct answer is B: Hypervolemia. A bounding pulse is characterized by a strong and forceful heartbeat, which is typically associated with an increased volume of blood in the circulatory system. In hypervolemia, there is an excess of fluid in the blood vessels, leading to increased pressure and volume, resulting in a bounding pulse. Hypovolemia (choice A) is characterized by decreased blood volume and would not cause a bounding pulse. Aortic stenosis (choice C) is a narrowing of the aortic valve that leads to reduced blood flow from the heart and would not typically result in a bounding pulse. Bradycardia (choice D) is a slow heart rate and is not directly related to the strength or forcefulness of the pulse.
Question 4 of 5
The nurse is performing a cardiovascular assessment and notes that the patient has a weak and thready pulse. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Step 1: A weak and thready pulse indicates poor perfusion due to decreased blood volume. Step 2: Hypovolemia refers to low blood volume, leading to a weak pulse. Step 3: Hypervolemia is an excess of blood volume, which would not cause a weak pulse. Step 4: Aortic stenosis affects the heart valves, not directly causing a weak pulse. Step 5: Peripheral artery disease results in decreased blood flow to extremities, not affecting the pulse in general. Conclusion: The correct answer is A (Hypovolemia) because it directly correlates with the presentation of a weak and thready pulse, while the other choices are not the primary cause of this finding.
Question 5 of 5
The nurse is assessing a patient's lungs and hears a pleural friction rub. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Pleuritis. A pleural friction rub is caused by inflammation of the pleura, the lining of the lungs and chest cavity. This rubbing together of inflamed surfaces creates a characteristic grating sound. Pleuritis is the most likely cause of this finding because it directly involves the pleura. Pneumonia (A) typically presents with crackles or decreased breath sounds. Pulmonary embolism (C) usually manifests with sudden onset chest pain and shortness of breath. Chronic obstructive pulmonary disease (D) may present with wheezing or prolonged expiration but not a pleural friction rub.