ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is performing a pain assessment and asks the patient to describe the location of their pain. Which dimension of pain is being assessed?
Correct Answer: C
Rationale: The correct answer is C: Location. In pain assessment, evaluating the location of pain helps in determining the underlying cause and potential treatment options. Understanding the exact area of pain can provide crucial information for diagnosis and management. Intensity (A) refers to the severity of pain, quality (B) describes the characteristics of pain, and duration (D) indicates how long the pain lasts. These dimensions are important but in this case, the focus is on identifying the specific site of pain to guide further assessment and intervention.
Question 2 of 5
The nurse is assessing a patient's respiratory status and notes that the patient is using their neck muscles to breathe. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Severe respiratory distress. When a patient is using their neck muscles to breathe, it indicates that they are struggling to breathe effectively. This is a sign of increased work of breathing, which is commonly seen in severe respiratory distress. The neck muscles are recruited as accessory muscles to help with breathing when the respiratory system is compromised. This finding can be seen in conditions such as severe asthma, acute respiratory failure, or severe pneumonia. Therefore, the most likely cause of a patient using their neck muscles to breathe is severe respiratory distress. Summary: - Choice B (Hyperventilation): Hyperventilation is characterized by rapid and deep breathing, not necessarily the use of neck muscles to breathe. - Choice C (Pneumothorax): Pneumothorax typically presents with chest pain and shortness of breath, but not specifically with the use of neck muscles to breathe. - Choice D (Acute bronchitis): Acute bronchitis
Question 3 of 5
The nurse is assessing a patient's abdomen and notices rebound tenderness. What condition does this finding suggest?
Correct Answer: B
Rationale: Rebound tenderness, where pain worsens upon releasing pressure, is a sign of peritonitis, inflammation of the abdominal lining. This suggests an urgent medical issue involving the peritoneum. Cholecystitis (A) is inflammation of the gallbladder, not the peritoneum. Appendicitis (C) involves the appendix, not the peritoneum. Diverticulitis (D) is inflammation of diverticula in the colon, not the peritoneum. Peritonitis is the correct answer due to the specific association of rebound tenderness with peritoneal inflammation.
Question 4 of 5
A 40-year-old woman presents with a complaint of frequent urination and increased thirst. She reports that these symptoms have been present for several weeks. She has a family history of diabetes mellitus. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for the 40-year-old woman presenting with frequent urination, increased thirst, and a family history of diabetes mellitus is diabetes mellitus (Choice A). 1. Symptoms of frequent urination and increased thirst are classic signs of diabetes mellitus. 2. Family history of diabetes increases the likelihood of developing the condition. 3. Other choices are less likely: - Urinary tract infection (Choice B) typically presents with symptoms such as pain or burning sensation during urination, fever, and cloudy urine. - Hypercalcemia (Choice C) is characterized by elevated levels of calcium in the blood and is not directly related to the symptoms described. - Cystitis (Choice D) is inflammation of the bladder and usually presents with symptoms like pain or discomfort in the pelvic area, frequent urination, and urgency to urinate. In summary, based on the patient's symptoms and family history, diabetes mellitus is the most likely diagnosis, while the other choices
Question 5 of 5
The nurse is performing an abdominal assessment and notes that the patient has rebound tenderness. What is the most likely cause of this finding?
Correct Answer: A
Rationale: Rebound tenderness is indicative of peritonitis, an inflammation of the peritoneum. Appendicitis, which involves inflammation of the appendix, commonly leads to peritonitis due to perforation. Therefore, the correct answer is A: Appendicitis. Cholecystitis (B), pancreatitis (C), and diverticulitis (D) do not typically cause peritonitis and rebound tenderness.