ATI RN
Assess Vital Signs Questions
Question 1 of 5
Which critical thinking skill helps the nurse see relationships among the data?
Correct Answer: B
Rationale: The correct answer is B: Clustering related cues. This critical thinking skill helps the nurse to see relationships among the data by grouping together related information. By clustering similar cues, the nurse can identify patterns, trends, and connections that may not be immediately obvious when data is scattered. This process aids in drawing meaningful conclusions and making informed decisions. Validation (choice A) involves confirming the accuracy and reliability of the data, not necessarily seeing relationships among them. Identifying gaps in data (choice C) focuses on recognizing missing information rather than analyzing relationships. Distinguishing relevant from irrelevant (choice D) is important in data analysis but does not specifically address the skill of seeing relationships among data.
Question 2 of 5
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
Correct Answer: D
Rationale: The correct answer is D because in an outpatient setting for cold and flu symptoms, a focused or problem-centered history is appropriate to quickly assess the current issue. Step 1: Identify the presenting problem - cold and flu symptoms. Step 2: Gather specific information related to the issue. Step 3: Focus on relevant history questions to determine the cause and appropriate intervention. Other choices are incorrect because they may require a comprehensive history for long-term care (A), immediate intervention for severe shortness of breath (B), or pre-operative assessment for surgery (C).
Question 3 of 5
A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely?
Correct Answer: A
Rationale: The correct answer is A: Otosclerosis of the left ear. In otosclerosis, there is abnormal bone growth in the middle ear that affects sound conduction. In this case, bone conduction being greater than air on the left indicates a conductive hearing loss, which is consistent with otosclerosis. The Weber test showing the sound better on the left ear suggests a lateralization towards the affected ear, supporting the diagnosis. Incorrect choices: B: Exposure to chronic loud noise of the right ear would likely result in sensorineural hearing loss, not a conductive hearing loss as seen in this case. C: Otitis media of the right ear would also lead to conductive hearing loss, but the abnormal findings are consistent with left ear involvement, making this choice incorrect. D: Perforation of the right eardrum would result in a conductive hearing loss in the right ear, not the left ear as observed in this patient.
Question 4 of 5
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
Correct Answer: D
Rationale: The correct answer is D because ascites is fluid accumulation in the peritoneal cavity, causing a shifting dullness or fluid wave. Tympany that changes location with patient position (shifting dullness) is a classic finding in ascites, indicating the presence of fluid. Choices A, B, and C do not specifically indicate ascites. Bilateral flank tympany (choice A) is associated with bowel sounds, dullness that remains despite position change (choice B) may suggest a solid mass, and dullness centrally when supine (choice C) could be due to other abdominal organ enlargement.
Question 5 of 5
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A. The significant change in blood pressure from 128/68 to 160/50, along with a significant decrease in pulse from 110 to 55, and a decrease in respirations from 26 to 14, indicates potential signs of deteriorating condition. A drop in blood pressure paired with a significant decrease in pulse and respirations could signify shock, which is a life-threatening condition that requires immediate intervention. Option B shows an increase in pulse and respirations, but the blood pressure remains within an acceptable range. Option C shows a slight increase in blood pressure with minimal changes in pulse and respirations. Option D shows a moderate decrease in pulse and a significant increase in respirations, but the blood pressure remains relatively stable. In summary, option A is the most concerning as it shows a combination of significant changes in blood pressure, pulse, and respirations, indicating a potential deterioration in the patient's condition.