ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is performing a cardiovascular assessment and notes a gallop rhythm on auscultation. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a gallop rhythm on auscultation is most likely associated with congestive heart failure. This rhythm indicates the presence of an additional heart sound, usually an S3 or S4, which can be heard in conditions where there is volume overload or increased filling pressures in the heart, such as in congestive heart failure. The S3 gallop is typically associated with volume overload, while the S4 gallop is associated with increased resistance to ventricular filling. Aortic stenosis, mitral valve prolapse, and tricuspid regurgitation typically present with different auscultatory findings such as murmurs or clicks, rather than a gallop rhythm.
Question 2 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the hip. What is the next step in the assessment?
Correct Answer: A
Rationale: The correct next step in this situation is to palpate the hip for tenderness. This is important to assess for any signs of inflammation, injury, or underlying musculoskeletal issues causing the limited range of motion. Palpation helps identify specific areas of discomfort or tenderness that may provide clues to the root cause of the limited range of motion. Performing passive range of motion (choice B) would be premature without first identifying any tenderness. Auscultating the joint for crepitus (choice C) is not necessary at this stage as it is more relevant in assessing joint sounds, not range of motion. Referring the patient for imaging (choice D) would be a later step after a more thorough assessment to confirm any suspected pathology.
Question 3 of 5
The nurse is performing a neurological assessment and notes that the patient has a positive Romberg sign. What does this finding indicate?
Correct Answer: C
Rationale: The Romberg test evaluates a person's ability to maintain balance with eyes closed. A positive Romberg sign indicates proprioceptive dysfunction, as the patient relies on visual input for balance. This suggests issues with sensory perception and coordination. Choice A is incorrect as a positive Romberg sign does not indicate normal coordination. Choice B is incorrect as cerebellar dysfunction would present with different signs. Choice D is incorrect as motor weakness would not be specifically indicated by a positive Romberg sign.
Question 4 of 5
Core temperatures are not measured at:
Correct Answer: D
Rationale: Sublingual site, is correct because it measures oral temperature, considered a surface reading, not a true core site. Core temperature reflects internal body heat (e.g., 98.6°F-100.4°F) and is taken at sites like Tympanic site (ear, near hypothalamus), Rectal site (most accurate), and Bladder (via catheter). Sublingual (under tongue) readings, while reliable, are slightly lower (~98.6°F) and influenced by air or food, making them non-core. Nursing distinguishes core for critical monitoring (e.g., hypothermia) versus surface for routine checks. Thus, D is the accurate choice, aligning with thermometry standards and physiological definitions.
Question 5 of 5
A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his mother's legs and asking to go home. Which of the following would be the best nursing intervention to accomplish this task?
Correct Answer: B
Rationale: A restless toddler clinging to the mother is likely anxious, making vital sign assessment challenging. Performing assessments with the child on the parent's lap provides comfort and stability, increasing cooperation and accuracy. Doing blood pressure first may heighten fear, as it involves a cuff that can feel restrictive, worsening the situation. Hiding instruments might reduce initial anxiety but doesn't address ongoing distress during measurement. Removing distractions could help focus but may not calm the child as effectively as parental presence. Choice B is best because it leverages the mother's comforting role, a proven pediatric nursing strategy to ease anxiety and facilitate procedures. This approach aligns with developmental considerations, prioritizing the child's emotional security to obtain reliable vital signs.