ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Head turned to the side. This position can potentially increase intracranial pressure by obstructing venous drainage and impeding blood flow. The rationale is to maintain cerebral perfusion and reduce the risk of complications. A: Head midline is correct as it promotes proper alignment and reduces strain on the neck muscles. C: Neck in neutral position is correct to prevent additional pressure on the neck and optimize blood flow. D: Head of bed elevated 30 to 45 degrees is correct to facilitate venous drainage and reduce intracranial pressure.
Question 2 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 3 of 5
Which of the following assessment findings is most consistent with chronic venous insufficiency?
Correct Answer: B
Rationale: The correct answer is B: Brown discoloration around the ankles. Chronic venous insufficiency is characterized by impaired venous return, leading to pooling of blood in the lower extremities. This results in hemosiderin deposition, causing brown discoloration around the ankles known as hemosiderin staining. Pale, cool skin (choice A) is more indicative of arterial insufficiency. Diminished pulses (choice C) are associated with arterial occlusive disease. Intermittent claudication (choice D) is a symptom of peripheral artery disease.
Question 4 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 5 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.