ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The nurse is assessing a patient's mental status and asks the patient to remember three words and repeat them after five minutes. Which aspect of memory is being tested?
Correct Answer: A
Rationale: The correct answer is A: Recent memory. This test assesses the ability to retain and recall information over a short period, typically within minutes. Immediate memory (choice C) refers to the ability to hold information briefly in the mind, but the question specifically mentions a delay of five minutes. Long-term memory (choice B) involves remembering information over a longer period. Remote memory (choice D) refers to the recall of information from the distant past, not recent events. By testing the patient's ability to remember and repeat three words after five minutes, the nurse is evaluating the patient's recent memory function.
Question 2 of 5
A 45-year-old woman presents with sudden onset of severe, unilateral lower abdominal pain. She also reports nausea and vomiting. On examination, she has tenderness to palpation in the right lower quadrant. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Ovarian cyst rupture. The sudden onset of severe, unilateral lower abdominal pain along with nausea and vomiting suggests a possible rupture of an ovarian cyst. The tenderness in the right lower quadrant can be due to the location of the affected ovary. Ovarian cyst rupture can mimic symptoms of appendicitis (choice A), but the absence of fever and rebound tenderness makes appendicitis less likely. Pelvic inflammatory disease (choice C) typically presents with bilateral lower abdominal pain and a history of vaginal discharge. Ectopic pregnancy (choice D) may present with similar symptoms, but the absence of vaginal bleeding and a positive pregnancy test makes it less likely in this case.
Question 3 of 5
The nurse is auscultating the heart and hears a high-pitched, blowing sound during systole. What does this finding most likely indicate?
Correct Answer: A
Rationale: The correct answer is A: Mitral valve prolapse. This is indicated by a high-pitched, blowing sound during systole, known as a systolic murmur. Mitral valve prolapse is characterized by the abnormal movement of the mitral valve leaflets during systole, leading to the regurgitation of blood back into the left atrium. The sound is a result of turbulent blood flow across the valve. Incorrect choices: B: Aortic stenosis typically presents with a harsh, crescendo-decrescendo systolic murmur heard best at the right upper sternal border. C: Tricuspid regurgitation produces a holosystolic murmur best heard at the left lower sternal border. D: Pulmonic stenosis is associated with a systolic ejection murmur heard best at the left upper sternal border.
Question 4 of 5
The nurse is assessing a patient's cranial nerve function and notes that the patient has absent corneal reflex on one side. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Unilateral facial nerve paralysis. The corneal reflex is mediated by the trigeminal nerve (cranial nerve V) afferent limb and facial nerve (cranial nerve VII) efferent limb. Absent corneal reflex on one side indicates a dysfunction in the facial nerve, which controls the blinking reflex in response to corneal stimulation. Trigeminal nerve dysfunction (choice B) would present with sensory deficits, not specifically affecting the corneal reflex. Upper motor neuron lesion (choice C) would typically present with bilateral findings, and lower motor neuron lesion (choice D) would affect the facial muscles directly, not the corneal reflex.
Question 5 of 5
The nurse is performing a cardiovascular assessment and hears a murmur during diastole. What condition is most likely associated with this finding?
Correct Answer: B
Rationale: Step-by-step rationale for why choice B, Mitral stenosis, is correct: 1. Mitral stenosis causes narrowing of the mitral valve, leading to turbulent blood flow during diastole, resulting in a diastolic murmur. 2. Aortic regurgitation (choice A) involves regurgitation of blood back into the left ventricle during diastole, causing a systolic murmur. 3. Tricuspid regurgitation (choice C) and pulmonary hypertension (choice D) also present with systolic murmurs, not diastolic as in the scenario described. In summary, the diastolic murmur heard during the cardiovascular assessment is most likely associated with mitral stenosis due to the narrowed mitral valve causing turbulent blood flow during diastole, differentiating it from the other choices.