ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse is assessing a patient's peripheral pulses and notes that the pulse is weak and thready. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Hypovolemia. Weak and thready pulses are indicative of decreased blood volume, which is a characteristic of hypovolemia. When there is not enough blood circulating in the body, peripheral pulses may become weak and difficult to palpate. Other choices are incorrect because: B: Hypervolemia would typically present with bounding pulses due to excess fluid volume. C: Arterial occlusion would result in absent or diminished pulses, not weak and thready pulses. D: Peripheral edema would not directly affect the strength or quality of peripheral pulses.
Question 2 of 5
During a cardiovascular assessment, the nurse notes that the patient has a jugular vein distension (JVD) when positioned at 45 degrees. What does this finding suggest?
Correct Answer: C
Rationale: The correct answer is C: Right-sided heart failure. Jugular vein distension (JVD) at 45 degrees indicates increased central venous pressure, commonly seen in right-sided heart failure. In this condition, the weakened right heart is unable to pump effectively, leading to venous congestion and JVD. Dehydration (B) typically presents with decreased jugular venous pressure. Pulmonary embolism (D) may cause JVD, but it's usually accompanied by other symptoms. JVD is not a normal finding (A) at 45 degrees and suggests an underlying pathology.
Question 3 of 5
During a musculoskeletal assessment, the nurse notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. In rheumatoid arthritis, patients typically present with tender, swollen joints and decreased range of motion due to joint inflammation and synovial thickening. This autoimmune condition affects multiple joints symmetrically. Osteoarthritis (A) is characterized by joint pain and stiffness, but not usually significant swelling or systemic symptoms like in rheumatoid arthritis. Gout (C) is characterized by sudden, severe pain, redness, and swelling, typically affecting one joint, often the big toe. Bursitis (D) is inflammation of the bursae sacs, causing localized pain and swelling, but not typically associated with significant joint stiffness or systemic symptoms as in rheumatoid arthritis.
Question 4 of 5
Core body temperature is ___ surface body temperature.
Correct Answer: B
Rationale: Higher than, is correct because core body temperature (e.g., rectal, tympanic) is typically 0.5°F-1°F higher than surface temperature (e.g., oral, axillary) due to proximity to internal organs and less environmental influence. Core sites reflect true metabolic heat, averaging 98.6°F-100.4°F, while surface sites like skin average 97°F-99°F. Less than, reverses this fact. Equal to, ignores the gradient. None of the above, dismisses the clear difference. This distinction is vital in nursinge.g., rectal readings are higher and more stable than axillary, guiding fever assessment. Physiological principles and clinical tools (e.g., thermometers) confirm B as the correct answer.
Question 5 of 5
A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient?
Correct Answer: B
Rationale: IV fluids in the right arm interfere with accurate blood pressure measurement due to altered circulation and pressure. Taking it in the left arm avoids this, ensuring a reliable reading. Using the right arm risks inaccuracy. A small cuff doesnt address the IV issue and may overestimate pressure. Reporting inability is unnecessary when the left arm is viable. Choice B is correct, reflecting standard practice to use the unaffected limb.