ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 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 2 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 3 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.
Question 4 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 5 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.