ATI RN
Assess Vital Signs Rationale Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is assessing a patient's capillary refill time. What is the normal finding for this assessment?
Correct Answer: B
Rationale: The correct answer is B: Less than 2 seconds. Capillary refill time measures the time it takes for blood to return to the capillaries after pressure is applied and released. A normal finding is less than 2 seconds, indicating adequate peripheral perfusion. Choices A, C, and D are incorrect as they exceed the normal capillary refill time, which could suggest inadequate circulation and potential perfusion issues. Choice A (<1 second) may indicate hypervolemia or vasodilation, while choices C (>3 seconds) and D (>4 seconds) may indicate hypovolemia or vasoconstriction, respectively. Hence, the correct answer is less than 2 seconds, as it indicates normal capillary refill time and adequate blood flow.
Question 5 of 5
During a skin assessment, the nurse notes that the patient has petechiae. What is the primary cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Capillary bleeding. Petechiae are tiny, pinpoint, round spots that appear on the skin due to bleeding under the skin. This is caused by capillaries leaking blood into the skin, leading to the characteristic appearance of petechiae. Dilated capillaries (A) do not directly cause petechiae. Increased melanin production (C) results in skin pigmentation changes, not petechiae. Loss of collagen (D) may lead to skin changes like sagging, but it is not the primary cause of petechiae.