ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
What is the correct technique for assessing the carotid arteries?
Correct Answer: C
Rationale: The correct technique for assessing the carotid arteries is to auscultate for bruits before palpating. This is important because listening for bruits can indicate the presence of any abnormal sounds or blockages in the arteries, which can affect the palpation results. Palpating before auscultating may disrupt any potential bruits that should be detected. Auscultating both arteries simultaneously (Choice A) is not recommended as it may lead to missing subtle differences between the two sides. Palpating both arteries simultaneously (Choice B) is not ideal as it may not allow for accurate assessment of each artery individually. Palpating the arteries firmly to assess for strength (Choice D) is not recommended as excessive pressure can lead to inaccurate results and potential harm.
Question 2 of 5
During an eye assessment, the nurse observes that the patient's pupils constrict when focusing on a near object. What is this response called?
Correct Answer: A
Rationale: Accommodation is the correct answer because it refers to the ability of the eye to adjust its focus when moving between objects at different distances. When the pupils constrict while focusing on a near object, it indicates the eye is accommodating to improve clarity for close-up vision. Convergence (B) is the coordinated movement of both eyes towards a near object, not pupil constriction. Refraction (C) is the bending of light as it passes through the eye, not the pupil's response. Visual acuity (D) is the sharpness of vision, not related to pupil constriction during accommodation.
Question 3 of 5
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. Which component is not included in this scale?
Correct Answer: D
Rationale: The correct answer is D: Pupil size. The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, motor response, and verbal response. Pupil size is not included in the GCS as it focuses on assessing the patient's neurological status and responsiveness to stimuli. Pupil size is typically assessed separately as part of a neurologic examination but is not a component of the GCS. Therefore, D is the correct answer. A, B, and C are incorrect because they are the three components (eye opening, motor response, verbal response) included in the Glasgow Coma Scale.
Question 4 of 5
The nurse is assessing a patient's respiratory system and notes the presence of stridor. What does this finding most likely indicate?
Correct Answer: B
Rationale: The presence of stridor indicates upper airway obstruction. Stridor is a high-pitched, inspiratory sound that occurs when there is partial obstruction in the upper airway, typically in the larynx or trachea. This sound is produced as air passes through a narrowed or partially blocked airway during inhalation. Lower airway obstruction (Choice A) typically presents with wheezing, not stridor. Pleural effusion (Choice C) is the accumulation of fluid in the pleural space, which would not cause stridor. Pulmonary edema (Choice D) is the accumulation of fluid in the lungs, leading to crackles on auscultation, not stridor.
Question 5 of 5
Which finding during a neurological assessment suggests damage to cranial nerve VIII (vestibulocochlear nerve)?
Correct Answer: B
Rationale: The correct answer is B: Loss of balance and hearing. Damage to cranial nerve VIII (vestibulocochlear nerve) affects balance and hearing as it is responsible for transmitting sensory information related to equilibrium and sound perception. Loss of balance indicates dysfunction in the vestibular component of the nerve, while hearing loss is related to the cochlear component. Difficulty swallowing (choice A) is associated with cranial nerves IX and X. Impaired eye movement (choice C) is linked to cranial nerves III, IV, and VI. Weakness in shoulder shrugging (choice D) is typically attributed to cranial nerve XI.