ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The nurse is auscultating heart sounds and notes a third heart sound (S3) in an adult. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a third heart sound (S3) in an adult is most commonly associated with heart failure. This sound occurs during early diastole when the ventricles are resistant to filling due to increased volume. In heart failure, the ventricles are often dilated and have impaired function, leading to the S3 sound. Aortic stenosis (B) typically presents with a systolic murmur, not an S3 sound. Mitral valve regurgitation (C) may present with a murmur but not typically an S3 sound. Pulmonary embolism (D) is associated with symptoms like chest pain, shortness of breath, and tachycardia, not an S3 sound.
Question 2 of 5
The nurse is auscultating the lungs and hears coarse crackles during inspiration. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The presence of coarse crackles during inspiration indicates fluid or secretions in the lungs, which are typically associated with pneumonia. Pneumonia is an acute infection of the lung parenchyma leading to inflammation and consolidation, causing crackles. Pulmonary fibrosis presents with fine crackles, not coarse crackles. Heart failure may present with crackles, but they are typically associated with expiratory crackles. COPD does not typically present with crackles on auscultation. Therefore, based on the symptom of coarse crackles during inspiration, the most likely condition is pneumonia.
Question 3 of 5
A 45-year-old woman presents with sudden onset of severe, unilateral lower abdominal pain. She also reports nausea and vomiting. On examination, she has tenderness to palpation in the right lower quadrant. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Ovarian cyst rupture. The sudden onset of severe, unilateral lower abdominal pain along with nausea and vomiting suggests a possible rupture of an ovarian cyst. The tenderness in the right lower quadrant can be due to the location of the affected ovary. Ovarian cyst rupture can mimic symptoms of appendicitis (choice A), but the absence of fever and rebound tenderness makes appendicitis less likely. Pelvic inflammatory disease (choice C) typically presents with bilateral lower abdominal pain and a history of vaginal discharge. Ectopic pregnancy (choice D) may present with similar symptoms, but the absence of vaginal bleeding and a positive pregnancy test makes it less likely in this case.
Question 4 of 5
The nurse is auscultating the heart and hears a high-pitched, blowing sound during systole. What does this finding most likely indicate?
Correct Answer: A
Rationale: The correct answer is A: Mitral valve prolapse. This is indicated by a high-pitched, blowing sound during systole, known as a systolic murmur. Mitral valve prolapse is characterized by the abnormal movement of the mitral valve leaflets during systole, leading to the regurgitation of blood back into the left atrium. The sound is a result of turbulent blood flow across the valve. Incorrect choices: B: Aortic stenosis typically presents with a harsh, crescendo-decrescendo systolic murmur heard best at the right upper sternal border. C: Tricuspid regurgitation produces a holosystolic murmur best heard at the left lower sternal border. D: Pulmonic stenosis is associated with a systolic ejection murmur heard best at the left upper sternal border.
Question 5 of 5
The nurse is assessing a patient's cranial nerve function and notes that the patient has absent corneal reflex on one side. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Unilateral facial nerve paralysis. The corneal reflex is mediated by the trigeminal nerve (cranial nerve V) afferent limb and facial nerve (cranial nerve VII) efferent limb. Absent corneal reflex on one side indicates a dysfunction in the facial nerve, which controls the blinking reflex in response to corneal stimulation. Trigeminal nerve dysfunction (choice B) would present with sensory deficits, not specifically affecting the corneal reflex. Upper motor neuron lesion (choice C) would typically present with bilateral findings, and lower motor neuron lesion (choice D) would affect the facial muscles directly, not the corneal reflex.