ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is performing an abdominal assessment and notes a bruit over the aorta. What does this finding indicate?
Correct Answer: B
Rationale: Step 1: A bruit is an abnormal sound caused by turbulent blood flow. Step 2: The presence of a bruit over the aorta indicates turbulent blood flow, possibly due to atherosclerosis or an aneurysm. Step 3: This finding is significant and requires further assessment and monitoring. Step 4: Therefore, choice B is correct as it accurately reflects the indication of a bruit over the aorta. Summary: Choices A, C, and D are incorrect because a bruit is not a normal vascular sound, does not indicate absence of bowel sounds, and is not related to increased peristalsis.
Question 2 of 5
The nurse is assessing a patient for signs of deep vein thrombosis (DVT). Which finding is most indicative of DVT?
Correct Answer: B
Rationale: The correct answer is B: Unilateral leg swelling and warmth. This finding is most indicative of DVT because it is a classic symptom, suggesting a blood clot in a deep vein. Unilateral leg swelling and warmth are commonly associated with DVT due to impaired blood flow. Cool, pale skin (A) is not specific to DVT. Bilateral leg edema (C) is more suggestive of heart failure or venous insufficiency. Weak pulses in both legs (D) are not typical of DVT and may indicate peripheral arterial disease. Unilateral leg swelling and warmth in the context of DVT assessment should prompt further investigation and intervention.
Question 3 of 5
During a neurological assessment, the nurse evaluates the patient's deep tendon reflexes (DTRs). A normal response is documented as:
Correct Answer: C
Rationale: The correct answer is C (2+). A normal deep tendon reflex response is typically graded as 2+. This indicates a normal response with brisk, expected reflexes. Option A (0) suggests no response, which would be abnormal. Option B (1+.) indicates a diminished response, while option D (3+.) suggests an exaggerated response, both of which are abnormal findings. Therefore, the correct answer is C as it represents the standard, expected reflex response during a neurological assessment.
Question 4 of 5
Which of the following techniques is most appropriate for assessing thyroid gland enlargement?
Correct Answer: B
Rationale: The correct answer is B: Palpation while the patient swallows. This technique is most appropriate for assessing thyroid gland enlargement because it allows the healthcare provider to feel for any abnormal swelling or nodules in the thyroid gland as the patient swallows. Percussion of the thyroid gland (A) is not commonly used for assessing thyroid gland enlargement. Auscultation for bruits over the thyroid gland (C) is more relevant for detecting abnormal blood flow and is not typically used as a primary method for assessing enlargement. Inspection of the neck veins (D) is unrelated to assessing thyroid gland enlargement.
Question 5 of 5
The nurse is assessing a patient's capillary refill time. What is the normal finding for this assessment?
Correct Answer: B
Rationale: The correct answer is B: Less than 2 seconds. Capillary refill time measures the time it takes for blood to return to the capillaries after pressure is applied and released. A normal finding is less than 2 seconds, indicating adequate peripheral perfusion. Choices A, C, and D are incorrect as they exceed the normal capillary refill time, which could suggest inadequate circulation and potential perfusion issues. Choice A (<1 second) may indicate hypervolemia or vasodilation, while choices C (>3 seconds) and D (>4 seconds) may indicate hypovolemia or vasoconstriction, respectively. Hence, the correct answer is less than 2 seconds, as it indicates normal capillary refill time and adequate blood flow.