ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse is auscultating the lungs and hears a high-pitched, musical sound on expiration. What does this sound indicate?
Correct Answer: A
Rationale: The correct answer is A: Wheezing. Wheezing is a high-pitched, musical sound on expiration caused by narrowing of airways. This indicates obstruction in the lower respiratory tract, commonly seen in conditions like asthma or COPD. Crackles (B) are discontinuous, crackling sounds heard on inspiration and indicate fluid in the alveoli. Pleural friction rub (C) is a grating, rubbing sound heard during inspiration and expiration, suggesting inflammation of the pleura. Stridor (D) is a high-pitched, harsh sound heard on inspiration, indicating upper airway obstruction.
Question 2 of 5
During a neurological assessment, the nurse observes that the patient has difficulty pronating and supinating the hands rapidly. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A cerebellar dysfunction. This finding indicates cerebellar dysfunction because the cerebellum is responsible for coordinating rapid, smooth movements such as pronation and supination. A dysfunction in the cerebellum can result in impaired coordination and control of these movements. Incorrect choices: B: A cranial nerve deficit - Cranial nerves do not directly control pronation and supination. C: Impaired proprioception - Proprioception is the sense of body position and movement, not directly related to pronation and supination. D: Weakness in the upper extremities - Pronation and supination are more about coordination than strength.
Question 3 of 5
The following information is best placed in which category? 'The patient has had three cesarean sections.'
Correct Answer: B
Rationale: The correct answer is B: Surgeries. The statement 'The patient has had three cesarean sections' pertains to a surgical procedure rather than adult illnesses, obstetrics/gynecology, or psychiatric conditions. Cesarean sections are a type of surgery performed during childbirth, not related to adult illnesses or psychiatric disorders. Therefore, the information best fits under the category of Surgeries.
Question 4 of 5
Which of the following symptoms is relevant to the respiratory system?
Correct Answer: B
Rationale: The correct answer is B: Cough. Cough is a symptom directly related to the respiratory system, indicating irritation or inflammation in the airways. Polyuria (A) is excessive urination related to the kidneys or endocrine system. Nausea (C) is associated with the gastrointestinal system. Dysphagia (D) is difficulty swallowing, which is related to the esophagus and not the respiratory system. Therefore, cough is the only symptom directly relevant to the respiratory system.
Question 5 of 5
The nurse is assessing a patient for jaundice. Which area is the most reliable for detecting this condition?
Correct Answer: A
Rationale: The correct answer is A: Sclera. The sclera is the most reliable area for detecting jaundice due to the high concentration of bilirubin in the blood, which causes a yellowing of the sclera. The yellow discoloration is easily visible in the white part of the eye. Palms of the hands, nail beds, and dorsum of the feet are less reliable areas for detecting jaundice as the yellowing may not be as noticeable or pronounced in these areas. Thus, assessing the sclera provides a clear and direct indication of jaundice.