ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
Which assessment finding is most consistent with left-sided heart failure?
Correct Answer: C
Rationale: The correct answer is C: Crackles in the lungs. Left-sided heart failure typically results in fluid buildup in the lungs, leading to crackles upon auscultation. This occurs due to the impaired ability of the left side of the heart to adequately pump blood, causing fluid to leak into the lungs. Peripheral edema (A) is more indicative of right-sided heart failure, where blood backs up in the systemic circulation. Jugular vein distension (B) is a sign of increased central venous pressure, often seen in right-sided heart failure. Ascites (D) is the accumulation of fluid in the abdominal cavity and is more commonly associated with liver or kidney disease rather than heart failure.
Question 2 of 5
The nurse is assessing a patient's cranial nerves. How is cranial nerve II (optic nerve) tested?
Correct Answer: A
Rationale: Step-by-step rationale for why option A is correct: 1. Optic nerve (CN II) is responsible for vision. 2. Testing visual acuity assesses the sharpness of vision. 3. Testing visual fields evaluates peripheral vision. 4. Both tests specifically assess the function of the optic nerve. 5. Assessing pupil response to light (B) tests CN III, CN IV, and CN VI. Eye movements (C) test CN III, IV, and VI. Testing hearing ability (D) involves CN VIII, the vestibulocochlear nerve.
Question 3 of 5
During a respiratory assessment, the nurse observes that the patient's chest moves asymmetrically during inspiration. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. During a pneumothorax, air enters the pleural space, causing lung collapse and leading to asymmetric chest movement during inspiration. This occurs because the affected lung cannot fully expand. Other choices are incorrect because pleural effusion and asthma exacerbation usually do not cause asymmetric chest movement, and COPD typically results in symmetric chest movement due to chronic air trapping.
Question 4 of 5
The nurse is assessing the abdomen of a patient and notes visible peristalsis. What does this finding most likely indicate?
Correct Answer: B
Rationale: Visible peristalsis indicates increased activity of the intestines in attempting to move contents along. This is commonly seen in intestinal obstruction, where the intestines are trying to push against the blockage. This finding is not associated with normal digestion, dehydration, or abdominal distension, making option B the correct answer.
Question 5 of 5
During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?
Correct Answer: A
Rationale: To assess a pulse deficit, the nurse should first measure the apical pulse (using a stethoscope at the apex of the heart) and the radial pulse (at the wrist) simultaneously for a full minute. This is because the apical pulse represents the heart's contraction and the radial pulse represents the pulse felt at the periphery. The difference between the two rates indicates a pulse deficit, which suggests that not all heartbeats are reaching the periphery. This method allows for a direct comparison between the heart rate and the peripheral pulse rate. The other choices are incorrect because measuring the pulse strength in both radial arteries (B) does not assess for a pulse deficit, auscultating for murmurs (C) is not directly related to assessing a pulse deficit, and palpating carotid and femoral pulses simultaneously (D) does not provide a comparison between the heart rate and peripheral pulse rate.