ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Which of the following best describes objective information?
Correct Answer: B
Rationale: The correct answer is B because it provides specific, measurable data (heart rate of 80 bpm) that is observable and quantifiable. Objective information is based on facts and observable phenomena, not subjective interpretations or feelings. Choices A, C, and D involve subjective statements from the patient, which can vary based on individual perception and interpretation, making them less reliable for making clinical decisions.
Question 2 of 5
The nurse is assessing a patient's mental status and asks the patient to recall three words. What is the nurse testing?
Correct Answer: A
Rationale: The correct answer is A: Recent memory. By asking the patient to recall three words, the nurse is assessing the patient's ability to remember information that was just presented to them, which falls under recent memory. This test helps evaluate the patient's immediate memory function and can provide insights into cognitive impairments or memory deficits. Incorrect choices: B: Long-term memory - This choice is incorrect because the nurse is assessing the patient's ability to recall information presented in the immediate past, not from a long time ago. C: Abstract reasoning - This choice is incorrect as assessing abstract reasoning involves tasks that require logical thinking and problem-solving, not simply recalling words. D: Orientation - This choice is incorrect because orientation refers to awareness of person, place, time, and situation, which is not being tested by asking the patient to recall three words.
Question 3 of 5
During a cardiovascular assessment, the nurse notes a bounding peripheral pulse. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Hypervolemia. Bounding peripheral pulses are typically associated with increased blood volume, which is a characteristic of hypervolemia. When the body has an excess of fluid, the pulse feels strong and full due to the increased volume of blood circulating in the arteries. In contrast: A: Hypovolemia is characterized by decreased blood volume, leading to weak and thready pulses. B: Aortic stenosis causes obstruction of blood flow from the left ventricle into the aorta, resulting in a weak, delayed, or diminished pulse. D: Atrial fibrillation is an irregular heart rhythm that can result in an irregular pulse, but it does not typically cause bounding pulses.
Question 4 of 5
During a physical assessment, the nurse observes that the patient has a positive Homan's sign. What condition does this finding suggest?
Correct Answer: A
Rationale: The positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which is a classic sign of deep vein thrombosis (DVT). This occurs due to blood clot formation in the deep veins of the lower extremities, leading to calf pain with movement. Peripheral artery disease (B) presents with symptoms of intermittent claudication, not calf pain with dorsiflexion. Venous insufficiency (C) causes swelling and skin changes, not specifically calf pain with dorsiflexion. Pulmonary embolism (D) presents with symptoms like chest pain, shortness of breath, and cough, not calf pain with dorsiflexion.
Question 5 of 5
The nurse is performing a cardiovascular assessment and notes a gallop rhythm on auscultation. What condition is this most likely associated with?
Correct Answer: A
Rationale: The presence of a gallop rhythm on auscultation is most likely associated with congestive heart failure. This rhythm indicates the presence of an additional heart sound, usually an S3 or S4, which can be heard in conditions where there is volume overload or increased filling pressures in the heart, such as in congestive heart failure. The S3 gallop is typically associated with volume overload, while the S4 gallop is associated with increased resistance to ventricular filling. Aortic stenosis, mitral valve prolapse, and tricuspid regurgitation typically present with different auscultatory findings such as murmurs or clicks, rather than a gallop rhythm.