ATI RN
Vital Signs Assessment Nursing Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A 50-year-old man presents with shortness of breath, a cough, and a history of smoking. He has a barrel-shaped chest and wheezing on auscultation. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's age, smoking history, barrel-shaped chest, wheezing, and chronic symptoms are indicative of COPD. COPD is a chronic lung condition characterized by airflow obstruction and difficulty breathing. Pneumonia (A) typically presents with acute symptoms like fever and productive cough, not chronic symptoms. Asthma (C) usually presents with episodic symptoms and may have a different pattern of wheezing. Pulmonary embolism (D) presents with acute onset of shortness of breath and chest pain, not chronic symptoms like in this case.
Question 5 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the shoulder. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Frozen shoulder (adhesive capsulitis). Frozen shoulder is characterized by pain and stiffness in the shoulder joint, leading to limited range of motion. The condition typically progresses through three stages: freezing, frozen, and thawing. During the freezing stage, inflammation and scarring of the shoulder capsule cause pain and restricted movement. In contrast, osteoarthritis primarily affects the joints, causing pain, stiffness, and reduced range of motion over time. Rheumatoid arthritis is a systemic autoimmune condition that can cause joint inflammation, but it usually affects multiple joints symmetrically. Bursitis involves inflammation of the bursae, fluid-filled sacs that cushion the joints, leading to pain and swelling but not necessarily restricted range of motion in the shoulder.