ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is assessing the patient's ability to stand on one leg with their eyes closed. Which aspect of neurological function is being tested?
Correct Answer: A
Rationale: The correct answer is A: Proprioception and balance. Standing on one leg with eyes closed tests proprioception, the body's awareness of its position in space, and balance, the ability to maintain an upright posture. This task primarily involves sensory input from the lower extremities and integration in the brain. B: Cerebellar function primarily involves coordination and fine motor control, not specifically tested by standing on one leg with eyes closed. C: Cranial nerve function typically assesses functions such as vision, facial sensation, and muscle movement, not directly tested by this task. D: Coordination involves the integration of motor skills, which are not the primary focus of standing on one leg with eyes closed.
Question 2 of 5
The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger. Which aspect of neurological function is being tested?
Correct Answer: D
Rationale: The correct answer is D: Coordination and balance. When the nurse asks the patient to touch their nose with their finger, they are assessing the patient's ability to perform a coordinated movement accurately. This test specifically evaluates the patient's coordination and balance, as it involves the integration of sensory input and motor output. The cerebellum plays a crucial role in coordinating movements, making option A partially correct but not as specific as option D. Cranial nerve function (option B) is not directly assessed with this task. Proprioception (option C) refers to the awareness of the position and movement of the body, which is important for coordination but not the primary focus of this test.
Question 3 of 5
The nurse is assessing a patient's lungs and hears wheezing during exhalation. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Asthma. Wheezing during exhalation is a common characteristic of asthma due to airway constriction. In asthma, the airways become inflamed and narrowed, leading to difficulty in breathing and wheezing sounds during exhalation. Asthma is a chronic condition that can be triggered by various factors such as allergens or exercise. Summary of Incorrect Choices: B: Pulmonary fibrosis - Pulmonary fibrosis is characterized by scarring of lung tissue, leading to stiff and less flexible lungs. It typically presents with crackles on auscultation, not wheezing. C: Pneumonia - Pneumonia is an infection of the lung tissue, usually presenting with crackles or decreased breath sounds, not typically wheezing. D: Pulmonary embolism - Pulmonary embolism is a blockage in the pulmonary artery, often causing sudden shortness of breath and chest pain, but not typically associated with whe
Question 4 of 5
The nurse is assessing a patient for signs of heart failure. Which finding is most consistent with this condition?
Correct Answer: A
Rationale: The correct answer is A: Edema in the lower extremities. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the body, causing edema. Increased respiratory rate (B) may occur but is not specific to heart failure. Decreased blood pressure (C) and bounding pulse (D) are not typically seen in heart failure but may be present in other conditions. Edema is a classic sign of heart failure due to fluid retention from decreased cardiac output.
Question 5 of 5
The nurse is auscultating a patient's heart sounds and notes a high-pitched, blowing sound during systole. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Aortic stenosis. This is indicated by a high-pitched, blowing sound during systole known as an ejection murmur. Aortic stenosis involves narrowing of the aortic valve, causing turbulent blood flow during systole. Mitral valve prolapse (B) presents with a mid-systolic click and late systolic murmur. Tricuspid regurgitation (C) results in a holosystolic murmur. Pulmonary regurgitation (D) typically presents with a diastolic murmur.