ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 5 seconds in an adult is considered delayed and may indicate poor perfusion or circulatory issues. The nurse should investigate further to determine the underlying cause. Option A is incorrect as frostbite history does not directly relate to the capillary refill time in this scenario. Option B is incorrect as venous insufficiency does not typically affect capillary refill time. Option D is incorrect because a capillary refill time of 5 seconds is not considered normal in adults and warrants further evaluation.
Question 2 of 5
A 26-year-old violinist comes to your clinic, complaining of anxiety. He is a first chair violinist in the local symphony orchestra and has started having symptoms during performances, such as sweating, shaking, and hyperventilating. It has gotten so bad that he has thought about giving up his first chair status so he does not have to play the solo during one of the movements. He says that he never has these symptoms during rehearsals or when he is practicing. He denies having any of these symptoms at any other time. His past medical history is unremarkable. He denies any tobacco use, drug use, or alcohol abuse. His parents are both healthy. On examination you see a young man who appears worried. His vital signs and physical examination are unremarkable. What type of anxiety disorder best describes his situation?
Correct Answer: C
Rationale: The correct answer is C: Social phobia. The patient's symptoms of anxiety specifically occur in performance situations, such as playing solos with the orchestra, but not during rehearsals or practice sessions. This is characteristic of social phobia, also known as social anxiety disorder. Social phobia involves intense fear or anxiety about social situations where the individual may be scrutinized or judged, leading to avoidance of those situations. In this case, the patient's fear and anxiety are triggered by performing in front of an audience, which aligns with the diagnosis of social phobia. Choice A, Panic disorder, is incorrect because the patient's symptoms are specifically related to performance situations and not sudden, unexpected panic attacks. Choice B, Specific phobia, is incorrect because the fear is not related to a specific object or situation but rather to performing in front of others. Choice D, Generalized anxiety disorder, is incorrect because the patient's anxiety is not pervasive across various aspects of his life but is focused on
Question 3 of 5
G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. c. Lives alone, no family in the area
Correct Answer: C
Rationale: The correct answer is C: Third-level. The patient's presentation suggests he may be experiencing a cardiac event requiring immediate attention (first-level). The fact that he lives alone with no family in the area is a social issue (third-level) that could impact his ability to receive necessary ongoing care and support post-discharge, but it does not pose an immediate threat to his life. Therefore, addressing his immediate medical needs takes precedence over this social issue. Choices A and B are incorrect as they do not accurately reflect the urgency and priority level of the patient's problems.
Question 4 of 5
Nonverbal behaviors are just as important as verbal behaviors. Please mark the following behaviors as positive or negative. a. Tapping a pen rhythmically on the table.
Correct Answer: B
Rationale: The correct answer is B: Negative. Tapping a pen rhythmically on the table can be distracting to others and disrupt the communication process. It can convey impatience, nervousness, or lack of focus. Nonverbal behaviors should support and enhance verbal communication, not detract from it. Other choices are not applicable as the behavior described is clearly negative.
Question 5 of 5
During which type of contraction is a hamstring injury most likely to occur?
Correct Answer: B
Rationale: The correct answer is B: Eccentric muscle contraction. During eccentric contractions, the muscle lengthens while generating force, placing greater stress on the muscle fibers and making them more susceptible to injury. In the case of the hamstring, which is commonly injured during activities involving sudden deceleration or slowing down, such as running downhill or stopping abruptly, the eccentric contraction plays a significant role. Choice A (Concentric muscle contraction) involves muscle shortening and is less likely to cause injury in the hamstring. Choice C (Isometric contractions) involve static muscle contractions with no change in muscle length, making them less likely to lead to hamstring injury. Choice D (Isotonic contractions) refers to muscle contractions with a constant load, which may or may not lead to hamstring injury depending on the specific exercise and load applied.