ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is auscultating the abdomen and hears high-pitched, tinkling sounds. What does this finding most likely indicate?
Correct Answer: C
Rationale: The high-pitched, tinkling sounds heard during auscultation of the abdomen indicate bowel obstruction. This is due to the increased peristalsis and fluid and gas moving through the obstructed bowel, causing the tinkling noise. Normal peristalsis (choice A) would not produce such sounds. Gastrointestinal reflux (choice B) is associated with heartburn and regurgitation, not tinkling sounds. Ascites (choice D) is the accumulation of fluid in the peritoneal cavity and would not produce the described tinkling sounds. In summary, the tinkling sounds suggest bowel obstruction due to increased peristalsis and fluid and gas movement, making choice C the correct answer.
Question 2 of 5
During a cardiovascular assessment, the nurse notes a bounding peripheral pulse. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Hypervolemia. Bounding peripheral pulses are typically associated with increased blood volume, which is a characteristic of hypervolemia. When the body has an excess of fluid, the pulse feels strong and full due to the increased volume of blood circulating in the arteries. In contrast: A: Hypovolemia is characterized by decreased blood volume, leading to weak and thready pulses. B: Aortic stenosis causes obstruction of blood flow from the left ventricle into the aorta, resulting in a weak, delayed, or diminished pulse. D: Atrial fibrillation is an irregular heart rhythm that can result in an irregular pulse, but it does not typically cause bounding pulses.
Question 3 of 5
During a physical assessment, the nurse observes that the patient has a positive Homan's sign. What condition does this finding suggest?
Correct Answer: A
Rationale: The positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which is a classic sign of deep vein thrombosis (DVT). This occurs due to blood clot formation in the deep veins of the lower extremities, leading to calf pain with movement. Peripheral artery disease (B) presents with symptoms of intermittent claudication, not calf pain with dorsiflexion. Venous insufficiency (C) causes swelling and skin changes, not specifically calf pain with dorsiflexion. Pulmonary embolism (D) presents with symptoms like chest pain, shortness of breath, and cough, not calf pain with dorsiflexion.
Question 4 of 5
The nurse is performing a cardiovascular assessment and notes a gallop rhythm on auscultation. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a gallop rhythm on auscultation is most likely associated with congestive heart failure. This rhythm indicates the presence of an additional heart sound, usually an S3 or S4, which can be heard in conditions where there is volume overload or increased filling pressures in the heart, such as in congestive heart failure. The S3 gallop is typically associated with volume overload, while the S4 gallop is associated with increased resistance to ventricular filling. Aortic stenosis, mitral valve prolapse, and tricuspid regurgitation typically present with different auscultatory findings such as murmurs or clicks, rather than a gallop rhythm.
Question 5 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg sign is a test of proprioception. A positive Romberg sign indicates impaired proprioception, where the patient is unable to maintain balance with eyes closed due to dysfunction in proprioceptive pathways. This is the correct answer (C). Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar ataxia presents with a different set of symptoms. Choice D is incorrect as sensory neuropathy affects sensation, not proprioception.