ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is assessing a patient's respiratory status and notes that the patient is using their neck muscles to breathe. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Severe respiratory distress. When a patient is using their neck muscles to breathe, it indicates that they are struggling to breathe effectively. This is a sign of increased work of breathing, which is commonly seen in severe respiratory distress. The neck muscles are recruited as accessory muscles to help with breathing when the respiratory system is compromised. This finding can be seen in conditions such as severe asthma, acute respiratory failure, or severe pneumonia. Therefore, the most likely cause of a patient using their neck muscles to breathe is severe respiratory distress. Summary: - Choice B (Hyperventilation): Hyperventilation is characterized by rapid and deep breathing, not necessarily the use of neck muscles to breathe. - Choice C (Pneumothorax): Pneumothorax typically presents with chest pain and shortness of breath, but not specifically with the use of neck muscles to breathe. - Choice D (Acute bronchitis): Acute bronchitis
Question 2 of 5
A 40-year-old woman presents with a complaint of frequent urination and increased thirst. She reports that these symptoms have been present for several weeks. She has a family history of diabetes mellitus. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for the 40-year-old woman presenting with frequent urination, increased thirst, and a family history of diabetes mellitus is diabetes mellitus (Choice A). 1. Symptoms of frequent urination and increased thirst are classic signs of diabetes mellitus. 2. Family history of diabetes increases the likelihood of developing the condition. 3. Other choices are less likely: - Urinary tract infection (Choice B) typically presents with symptoms such as pain or burning sensation during urination, fever, and cloudy urine. - Hypercalcemia (Choice C) is characterized by elevated levels of calcium in the blood and is not directly related to the symptoms described. - Cystitis (Choice D) is inflammation of the bladder and usually presents with symptoms like pain or discomfort in the pelvic area, frequent urination, and urgency to urinate. In summary, based on the patient's symptoms and family history, diabetes mellitus is the most likely diagnosis, while the other choices
Question 3 of 5
The nurse is performing an abdominal assessment and notes that the patient has rebound tenderness. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Rebound tenderness is indicative of peritonitis, an inflammation of the peritoneum. Appendicitis, which involves inflammation of the appendix, commonly leads to peritonitis due to perforation. Therefore, the correct answer is A: Appendicitis. Cholecystitis (B), pancreatitis (C), and diverticulitis (D) do not typically cause peritonitis and rebound tenderness.
Question 4 of 5
During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Palpation with deep pressure on the right upper quadrant. This technique is appropriate because the liver is located in the right upper quadrant of the abdomen, and palpation with deep pressure allows the nurse to feel for any enlargement or abnormalities. Percussion (Choice A) is used to identify organ borders, not necessarily to assess for enlargement. Auscultation for liver bruits (Choice C) is not typically done during a routine abdominal examination for liver enlargement. Inspection for visible pulsations (Choice D) is more indicative of an abdominal aortic aneurysm, not liver enlargement.
Question 5 of 5
The nurse is performing a musculoskeletal assessment and 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. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.