ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is assessing a patient's mental status and asks the patient to recall three words. What is the nurse testing?
Correct Answer: A
Rationale: The correct answer is A: Recent memory. By asking the patient to recall three words, the nurse is assessing the patient's ability to remember information that was just presented to them, which falls under recent memory. This test helps evaluate the patient's immediate memory function and can provide insights into cognitive impairments or memory deficits. Incorrect choices: B: Long-term memory - This choice is incorrect because the nurse is assessing the patient's ability to recall information presented in the immediate past, not from a long time ago. C: Abstract reasoning - This choice is incorrect as assessing abstract reasoning involves tasks that require logical thinking and problem-solving, not simply recalling words. D: Orientation - This choice is incorrect because orientation refers to awareness of person, place, time, and situation, which is not being tested by asking the patient to recall three words.
Question 2 of 5
During a physical assessment, the nurse observes that the patient has a positive Homan's sign. What condition does this finding suggest?
Correct Answer: A
Rationale: The positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which is a classic sign of deep vein thrombosis (DVT). This occurs due to blood clot formation in the deep veins of the lower extremities, leading to calf pain with movement. Peripheral artery disease (B) presents with symptoms of intermittent claudication, not calf pain with dorsiflexion. Venous insufficiency (C) causes swelling and skin changes, not specifically calf pain with dorsiflexion. Pulmonary embolism (D) presents with symptoms like chest pain, shortness of breath, and cough, not calf pain with dorsiflexion.
Question 3 of 5
The nurse is performing a cardiovascular assessment and notes a gallop rhythm on auscultation. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a gallop rhythm on auscultation is most likely associated with congestive heart failure. This rhythm indicates the presence of an additional heart sound, usually an S3 or S4, which can be heard in conditions where there is volume overload or increased filling pressures in the heart, such as in congestive heart failure. The S3 gallop is typically associated with volume overload, while the S4 gallop is associated with increased resistance to ventricular filling. Aortic stenosis, mitral valve prolapse, and tricuspid regurgitation typically present with different auscultatory findings such as murmurs or clicks, rather than a gallop rhythm.
Question 4 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg sign is a test of proprioception. A positive Romberg sign indicates impaired proprioception, where the patient is unable to maintain balance with eyes closed due to dysfunction in proprioceptive pathways. This is the correct answer (C). Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar ataxia presents with a different set of symptoms. Choice D is incorrect as sensory neuropathy affects sensation, not proprioception.
Question 5 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the hip. What is the next step in the assessment?
Correct Answer: A
Rationale: The correct next step in this situation is to palpate the hip for tenderness. This is important to assess for any signs of inflammation, injury, or underlying musculoskeletal issues causing the limited range of motion. Palpation helps identify specific areas of discomfort or tenderness that may provide clues to the root cause of the limited range of motion. Performing passive range of motion (choice B) would be premature without first identifying any tenderness. Auscultating the joint for crepitus (choice C) is not necessary at this stage as it is more relevant in assessing joint sounds, not range of motion. Referring the patient for imaging (choice D) would be a later step after a more thorough assessment to confirm any suspected pathology.