ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is conducting a respiratory assessment. Which finding requires immediate attention?
Correct Answer: D
Rationale: The correct answer is D: Use of accessory muscles during breathing. This finding indicates respiratory distress and requires immediate attention as it suggests the patient is having difficulty breathing effectively. Accessory muscle use signifies increased work of breathing and potential respiratory compromise. A: A respiratory rate of 16 breaths per minute is within the normal range. B: An SpO2 of 92% on room air is slightly below the normal range but may not require immediate intervention. C: Bilateral lung sounds clear to auscultation indicate normal breath sounds and do not suggest imminent respiratory distress.
Question 2 of 5
A physical therapist completes an examination on a five-year-old boy diagnosed with Duchenne muscular dystrophy. The referral indicates that the boy was diagnosed with the disease less than one year ago. Assuming a normal progression, which of the following would be expected?
Correct Answer: B
Rationale: The correct answer is B: Proximal muscle weakness. In Duchenne muscular dystrophy, proximal muscle weakness is typically one of the earliest signs due to the progressive degeneration of muscle fibers. This weakness starts in the pelvic girdle and lower extremities before affecting the upper extremities. Distal muscle weakness (choice A) occurs later in the disease progression. Impaired respiratory function (choice C) is also a common feature in Duchenne muscular dystrophy but usually develops later in the disease course. Inability to perform activities of daily living (choice D) may occur eventually, but proximal muscle weakness is the more immediate and expected outcome in a newly diagnosed five-year-old with Duchenne muscular dystrophy.
Question 3 of 5
A physical therapist observes a patient completing a treadmill exercise test. The patient's blood pressure rises significantly during exercise. The therapist should recognize this as:
Correct Answer: A
Rationale: The correct answer is A: A normal response to exercise. During exercise, it is common for blood pressure to increase as the body works harder to supply oxygen to the muscles. This is known as the exercise pressor response and is a normal physiological reaction to physical activity. It helps the body meet the increased demand for oxygen during exercise. Choices B, C, and D are incorrect because a rise in blood pressure during exercise is generally expected and not necessarily indicative of an issue that requires test termination, poor cardiovascular fitness, or a contraindication to exercise.
Question 4 of 5
The nurse is performing a physical assessment and observes that the patient has a barrel-shaped chest. This finding is most commonly associated with which condition?
Correct Answer: B
Rationale: Barrel-shaped chest is most commonly associated with COPD due to chronic air trapping and hyperinflation of the lungs. In COPD, the increased residual volume leads to a more rounded appearance of the chest. Asthma typically presents with wheezing and chest tightness, not barrel chest. Pneumonia is characterized by lung consolidation and pleural effusion by fluid accumulation in the pleural space, neither of which directly causes a barrel-shaped chest.
Question 5 of 5
Which of the following findings is most concerning during a skin assessment?
Correct Answer: B
Rationale: The correct answer is B because a lesion that bleeds easily and does not heal could be indicative of skin cancer, such as melanoma. This finding is concerning as it suggests potential malignancy and requires immediate medical attention. A: A mole with uniform color and well-defined borders is typically considered benign and not as concerning during a skin assessment. C: A freckle that has not changed in size over several years is generally not worrisome as stable freckles are usually harmless. D: A birthmark present since infancy is usually harmless and not a cause for concern during a skin assessment.