ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is teaching a patient about hypertension management. Which statement by the patient indicates a need for further teaching?
Correct Answer: B
Rationale: Correct Answer: B Rationale: Choice B indicates a misunderstanding as stopping medications once blood pressure is normal can lead to uncontrolled hypertension. Patients with hypertension typically require long-term medication management to maintain blood pressure within a healthy range. This choice reflects a need for further teaching to emphasize the importance of medication adherence. Summary: A: Checking blood pressure regularly is a good practice for hypertension management. C: Reducing salt and processed food intake helps in managing hypertension. D: Incorporating exercise into daily routine is beneficial for hypertension management.
Question 2 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 3 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 4 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.
Question 5 of 5
Which of the following techniques is most appropriate for assessing thyroid gland enlargement?
Correct Answer: B
Rationale: The correct answer is B: Palpation while the patient swallows. This technique is most appropriate for assessing thyroid gland enlargement because it allows the healthcare provider to feel for any abnormal swelling or nodules in the thyroid gland as the patient swallows. Percussion of the thyroid gland (A) is not commonly used for assessing thyroid gland enlargement. Auscultation for bruits over the thyroid gland (C) is more relevant for detecting abnormal blood flow and is not typically used as a primary method for assessing enlargement. Inspection of the neck veins (D) is unrelated to assessing thyroid gland enlargement.