ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 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 2 of 5
The nurse is performing a cardiovascular assessment and hears a murmur during diastole. What condition is most likely associated with this finding?
Correct Answer: B
Rationale: Step-by-step rationale for why choice B, Mitral stenosis, is correct: 1. Mitral stenosis causes narrowing of the mitral valve, leading to turbulent blood flow during diastole, resulting in a diastolic murmur. 2. Aortic regurgitation (choice A) involves regurgitation of blood back into the left ventricle during diastole, causing a systolic murmur. 3. Tricuspid regurgitation (choice C) and pulmonary hypertension (choice D) also present with systolic murmurs, not diastolic as in the scenario described. In summary, the diastolic murmur heard during the cardiovascular assessment is most likely associated with mitral stenosis due to the narrowed mitral valve causing turbulent blood flow during diastole, differentiating it from the other choices.
Question 3 of 5
This condition may produce a subnormal temperature:
Correct Answer: C
Rationale: Hypothyroidism, is correct because an underactive thyroid reduces metabolism, lowering heat production and thus body temperature (e.g., below 97°F). Cerebral palsy, affects movement, not thermoregulation directly. Infection, typically raises temperature (fever). Fever, by definition increases temperature. Hypothyroidism slows cellular activity, impairing the bodys ability to maintain normal temperature, often causing cold intolerance. Clinical evidence links it to subnormal readings, unlike the other options, which either elevate temperature or have no direct effect. Thus, C is the accurate choice based on endocrine physiology.
Question 4 of 5
A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
Correct Answer: A
Rationale: A blood pressure of 130/90 mmHg is mildly elevated (prehypertension or Stage 1 hypertension). Follow-up measurements are recommended to confirm if its persistent, as a single reading isnt diagnostic. Immediate treatment is premature without trends. Assuming anxiety dismisses the need for monitoring, which is risky. Dietary changes may help long-term but arent the first step. Choice A aligns with guidelines (e.g., AHA) for tracking blood pressure over time to establish a pattern, ensuring proper management.
Question 5 of 5
Which of the following is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound?
Correct Answer: B
Rationale: Doppler ultrasound enhances BP measurement in low-flow states. Standing isn't required. Centering the cuff over the artery ensures accuracy, a key guideline. Mercury manometers aren't Doppler-specific. Doppler tip placement is technique, not a guideline. Choice B is correct, aligning with proper cuff positioning per Doppler protocols.