ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 92/42 mm Hg indicates hypotension, which can be a sign of septic shock in a patient with bacterial meningitis. This finding requires immediate attention as it can lead to serious complications and requires prompt intervention to stabilize the patient's hemodynamic status. A: A positive Kernig's sign and complaints of a stiff neck are common findings in patients with bacterial meningitis but do not require immediate reporting as they are expected symptoms. C: A temperature of 101°F is slightly elevated but not a critical finding that necessitates immediate reporting compared to hypotension.
Question 2 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 3 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 4 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 5 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.