ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 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.
Question 2 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.
Question 3 of 5
The most appropriate position in obtaining a rectal temperature for an adult would be:
Correct Answer: C
Rationale: Sims, is correct because the Sims position (left lateral with upper leg flexed) provides optimal access to the rectum for temperature measurement in adults. It ensures patient comfort and safety while allowing the nurse to insert the probe accurately. Supine (lying flat on back), is impractical for rectal access. Fowlers (semi-sitting), is used for respiratory ease, not rectal procedures. Lateral (side-lying), is close but less specific than Sims, which includes leg positioning for better exposure. Rectal temperature, a core measurement, requires proper positioning to avoid discomfort or injury, and Sims is standard in clinical practice for its anatomical alignment, making C the most appropriate choice.
Question 4 of 5
A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments?
Correct Answer: A
Rationale: Pain stimulates the sympathetic nervous system, often increasing pulse rate as the body responds to stress, a common finding in acute abdominal pain. A decrease in body temperature isnt typical, as pain may elevate temperature if inflammation is present. A decrease in blood pressure could occur in shock but isnt a primary pain response; pain often increases blood pressure initially. An increase in respiratory depth (D replaced with E) and rate (E) may occur, but the correct answer focuses on A. Pain typically accelerates pulse and respiratory rate while potentially decreasing depth, not increasing it. Choice A is correct as it consistently aligns with physiological responses to severe pain, supported by clinical observations of tachycardia in painful conditions like appendicitis or perforation.
Question 5 of 5
A patient is taking medications to treat a heart arrhythmia. Which site should be used to assess pulse in this patient?
Correct Answer: D
Rationale: Arrhythmias disrupt peripheral pulse reliability, requiring a central site. Brachial and radial are peripheral, potentially missing beats. Dorsalis pedis is distal, less accurate for arrhythmias. Apical at the heart apex directly counts beats, unaffected by peripheral irregularities, making it correct. Choice D is standard for arrhythmia patients, ensuring accurate rate and rhythm assessment per cardiovascular nursing protocols.