ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
Correct Answer: B
Rationale: The correct answer is B because listening in a rough Z pattern allows the nurse to cover all areas where heart sounds can be best heard - aortic, pulmonic, tricuspid, and mitral. This technique ensures a systematic approach to auscultation, starting at the base of the heart and moving towards the apex where the mitral area is located. By inching the stethoscope in this pattern, the nurse can accurately identify any abnormalities in heart sounds. Choice A is incorrect as it does not provide a systematic approach to auscultation and may lead to missing certain areas. Choice C is incorrect as heart sounds should be listened to at all relevant areas, not just where the apical pulse is strongest. Choice D is incorrect as listening for all possible sounds at once may lead to confusion and missing subtle abnormalities.
Question 2 of 5
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
Correct Answer: B
Rationale: The correct answer is B: Enlarged and tender inguinal nodes. Infections in the foot can lead to regional lymphadenopathy, causing enlargement and tenderness in the inguinal nodes closest to the affected area. This is a common sign of local infection. A: Hard and fixed cervical nodes are not typical findings for an infection in the foot. Cervical nodes are located in the neck and would not be directly affected by a foot infection. C: Bilateral enlargement of the popliteal nodes is not a common finding in foot infections. Popliteal nodes are located behind the knees and would not be directly involved in a foot infection. D: Pelletlike nodes in the supraclavicular region are not expected findings for a foot infection. Supraclavicular nodes are located in the neck and are not typically involved in a localized foot infection.
Question 3 of 5
The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?
Correct Answer: C
Rationale: The correct answer is C: Palpable firm, small, shotty, mobile, and nontender lymph nodes. In a healthy 5-year-old with recent immunizations and no current illness, this finding is normal. Step 1: Palpable lymph nodes are expected in children due to their active immune system. Step 2: Small size, shotty consistency, and mobility indicate a benign and reactive nature. Step 3: Non-tender nodes suggest they are not inflamed or infected. Choices A, B, and D describe abnormal lymph node characteristics that could indicate infection or malignancy, which are not expected in this scenario.
Question 4 of 5
A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?
Correct Answer: B
Rationale: The correct answer is B: Small amplitude, weak. In congestive heart failure, the heart's ability to pump effectively is compromised, leading to reduced cardiac output. As a result, the pulse would be small in amplitude and weak. This is due to the heart's inability to generate enough force to produce a strong pulse. Choices A, C, and D are incorrect because in congestive heart failure, the pulse is not large amplitude, forceful, normal, or bigeminal. It is important to recognize the specific characteristics of the pulse in different medical conditions to make accurate assessments.
Question 5 of 5
You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Tachypnea (rapid breathing). This is a cue related to the patient's pain because pain can lead to increased respiratory rate as a physiological response. The body's natural reaction to pain is to increase breathing to provide more oxygen to tissues. Therefore, tachypnea is a relevant cue to assess pain levels. A: Normal skin turgor is not directly related to pain assessment. Skin turgor is typically assessed to evaluate hydration status. B: Normal S1, S2 heart sounds are not directly related to pain assessment. Heart sounds are assessed to evaluate cardiac function. C: Glowing skin is not a typical cue related to pain assessment. Glowing skin may be associated with overall health and well-being but is not directly related to pain.