ATI RN
Vital Signs Health Assessment Questions
Question 1 of 5
The nurse is performing an abdominal assessment and notes a positive Murphy's sign. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Cholecystitis. When a nurse elicits a positive Murphy's sign during an abdominal assessment, it indicates inflammation of the gallbladder, which is a classic sign of cholecystitis. Murphy's sign is elicited by asking the patient to take a deep breath while the nurse palpates the right upper quadrant of the abdomen just below the rib cage. If the patient stops breathing due to pain during inspiration, it suggests inflammation of the gallbladder pressing against the inflamed liver, indicating cholecystitis. Option B) Pancreatitis is incorrect because Murphy's sign is not typically associated with pancreatitis. Pancreatitis is usually characterized by epigastric pain radiating to the back, nausea, and vomiting. Option C) Appendicitis is incorrect because Murphy's sign is specific to cholecystitis and is not typically associated with inflammation of the appendix. Appendicitis usually presents with right lower quadrant pain, fever, and rebound tenderness at McBurney's point. Option D) Gastritis is incorrect because Murphy's sign is not associated with gastritis. Gastritis is inflammation of the stomach lining and presents with symptoms like epigastric pain, nausea, and bloating. Educationally, understanding the significance of Murphy's sign in diagnosing cholecystitis is crucial for nurses conducting abdominal assessments. Recognizing the correlation between this physical exam finding and the associated condition helps in prompt identification and appropriate management of the patient's health condition.
Question 2 of 5
A patient is experiencing dyspnea. What is the nurses priority action?
Correct Answer: B
Rationale: Dyspnea (shortness of breath) requires improving lung expansion. Elevating the head of the bed allows abdominal organs to shift downward, giving the diaphragm more room to move, easing breathing. Removing pillows might flatten the patient, worsening lung expansion. Elevating the foot could increase abdominal pressure on the diaphragm, exacerbating dyspnea. Taking blood pressure is secondary to addressing the immediate respiratory need. Choice B is the priority as it directly improves oxygenation, a critical nursing intervention rooted in anatomical and physiological principles for respiratory distress management.
Question 3 of 5
A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient?
Correct Answer: A
Rationale: Shallow breathing obscures visual counting, requiring alternatives. Auscultating lung sounds detects air movement, allowing a 30-second count doubled to 60 seconds, a reliable method. Palpating thorax excursion is less precise for rate. Pulse oximetry measures oxygen, not rate directly. Arterial blood gases assess gases, not frequency. Choice A is correct, per nursing practice, ensuring accurate respiratory assessment when inspection fails.
Question 4 of 5
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 and hematocrit 45% are normal. Oximetry 95% is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.
Question 5 of 5
According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, high blood pressure for adults is defined as...
Correct Answer: D
Rationale: NHLBI defines hypertension as 140 mmHg systolic or 90 mmHg diastolic , aligning with clinical standards (e.g., JNC 8). 120/80 is normal/prehypertension. 100/50 is low. 150/100 exceeds but isn't the threshold. Choice D is correct, reflecting NHLBI criteria nurses use to identify and manage high BP, a major cardiovascular risk factor.