ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The nurse is auscultating heart sounds and notes a split S2 during inspiration. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. During inspiration, the intrathoracic pressure decreases, causing the pulmonary artery to fill more slowly than the aorta, resulting in a split S2. This is a physiological phenomenon known as a respiratory split, which is considered normal. Choices B, C, and D are incorrect because they do not correlate with the specific finding of a split S2 during inspiration. Mitral valve regurgitation and aortic stenosis typically present with different auscultatory findings, while heart failure may manifest with additional signs and symptoms beyond just a split S2.
Question 2 of 5
The nurse is performing a neurological assessment and notes a positive Romberg test. What does this finding indicate?
Correct Answer: B
Rationale: The Romberg test assesses balance and postural stability. A positive Romberg test indicates a deficit in proprioception, which is commonly seen in cerebellar ataxia or vestibular dysfunction. The cerebellum and vestibular system play crucial roles in maintaining balance and coordination. Cranial nerve dysfunction (A) does not directly affect balance. Peripheral neuropathy (C) primarily affects sensation and motor function, not balance. Increased intracranial pressure (D) may present with other neurological signs, but not specifically a positive Romberg test. Therefore, the correct answer is B.
Question 3 of 5
Which assessment technique is used to evaluate for the presence of fluid in the abdominal cavity?
Correct Answer: B
Rationale: The correct answer is B: Shifting dullness. This technique involves percussing the abdomen to determine if there is a change from tympanic to dull sound while the patient changes positions. This change in sound indicates the presence of fluid in the abdominal cavity, known as ascites. Rebound tenderness (A) is used to assess for peritoneal irritation, not fluid. Light palpation (C) is used to assess superficial abdominal tenderness and masses, not fluid. Deep palpation (D) is used to assess for deeper abdominal masses or organ enlargement, not fluid.
Question 4 of 5
A 60-year-old man presents with difficulty swallowing. He reports that the difficulty has been present for several months and is associated with weight loss. He has a history of smoking and heavy alcohol use. On examination, he has a palpable mass in the upper abdomen. Which of the following is the most likely cause of his symptoms?
Correct Answer: A
Rationale: The most likely cause of the man's symptoms is esophageal cancer (Choice A) due to his age, symptoms of dysphagia and weight loss, history of smoking and heavy alcohol use, and the presence of a palpable mass in the upper abdomen on examination. Esophageal cancer commonly presents with difficulty swallowing, weight loss, and risk factors such as smoking and alcohol use. The palpable mass indicates a more advanced disease stage. Choice B (Achalasia) is less likely due to the presence of a palpable mass, which is not typical of achalasia. Choice C (Gastroesophageal reflux disease) typically presents with heartburn and regurgitation rather than dysphagia and weight loss. Choice D (Peptic ulcer disease) is less likely as it does not typically cause a palpable mass or significant weight loss.
Question 5 of 5
A 65-year-old man with a history of hypertension presents with a complaint of shortness of breath on exertion and swelling in his legs. His physical examination reveals bilateral pedal edema, crackles at the lung bases, and jugular venous distention. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Congestive heart failure. Given the patient's history of hypertension, presenting symptoms of shortness of breath, pedal edema, crackles in the lungs, and jugular venous distention are classic signs of congestive heart failure. These symptoms are indicative of fluid overload and impaired cardiac function leading to fluid accumulation in the lungs and extremities. Other choices can be ruled out based on the lack of corresponding symptoms and physical examination findings related to those conditions. Chronic obstructive pulmonary disease (A) typically presents with chronic cough, wheezing, and sputum production. Pulmonary embolism (C) presents with sudden onset dyspnea, chest pain, and tachycardia. Renal failure (D) may present with decreased urine output, electrolyte abnormalities, and signs of uremia.