ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is conducting a health assessment on a patient with suspected meningitis. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: The correct answer is B: Nuchal rigidity. This is because nuchal rigidity, or neck stiffness, is a classic sign of meningitis due to inflammation of the meninges. It is often accompanied by headache, fever, and altered mental status. The other choices are not typically associated with meningitis. A Babinski sign is indicative of upper motor neuron lesion, hyperactive deep tendon reflexes can be seen in conditions like hyperthyroidism or upper motor neuron disorders, and asymmetrical pupils could indicate a neurological deficit but are not specific to meningitis. Therefore, nuchal rigidity is the most consistent finding in a patient with suspected meningitis.
Question 2 of 5
The nurse is performing a cardiac assessment and hears a harsh, grating sound during both systole and diastole. What does this sound most likely indicate?
Correct Answer: C
Rationale: The correct answer is C: Pericardial friction rub. This sound is typically indicative of inflammation of the pericardial sac, causing the pericardial layers to rub against each other during both systole and diastole. This is a distinctive sound separate from murmurs. A and B are incorrect as they refer to murmurs which are typically heard during either systole (A) or diastole (B). D, mitral valve prolapse, would present with a mid-systolic click and late systolic murmur, not a continuous sound throughout the cardiac cycle like a pericardial friction rub.
Question 3 of 5
During a respiratory assessment, the nurse notes that the patient is using their accessory muscles to breathe. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Acute asthma exacerbation. When a patient is using accessory muscles to breathe, it indicates respiratory distress. In acute asthma exacerbation, airway constriction leads to difficulty breathing, causing the patient to use accessory muscles to aid in breathing. This is a characteristic feature of asthma exacerbation. Summary: - B: COPD is characterized by chronic airflow limitation, not typically associated with sudden use of accessory muscles. - C: Pneumothorax is a collapsed lung, which may cause shortness of breath but doesn't usually result in the use of accessory muscles. - D: Pulmonary embolism is a blockage in a pulmonary artery, which can lead to shortness of breath but doesn't typically cause the use of accessory muscles for breathing.
Question 4 of 5
During a neurological assessment, the nurse asks the patient to close their eyes and identify familiar objects. Which sensory function is being tested?
Correct Answer: D
Rationale: The correct answer is D: Stereognosis. This test assesses the patient's ability to identify familiar objects through touch and manipulation without visual cues. It specifically evaluates the integration of tactile, proprioceptive, and sensorimotor functions in the brain. The other options are incorrect because: A: Pain sensation is typically assessed using a pinprick test. B: Proprioception is evaluated through tests involving joint position sense and movement. C: Light touch sensation is tested by using a cotton wisp or a gentle touch stimulus.
Question 5 of 5
During a respiratory assessment, the nurse notes that the patient has a prolonged inspiratory phase. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Upper airway obstruction. A prolonged inspiratory phase suggests resistance to airflow during inhalation, which is characteristic of upper airway obstruction. This could be due to a blockage in the upper airway, such as by a foreign body or swelling. Asthma (A) and COPD (B) typically present with expiratory phase abnormalities, not prolonged inspiratory phase. Pneumonia (D) may cause crackles and decreased breath sounds, but not specifically a prolonged inspiratory phase.