ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
Which of the following examples includes information recorded in the 'plan' portion of the clinical record?
Correct Answer: B
Rationale: The correct answer is B because the 'plan' portion of the clinical record typically includes details about the intended course of action for the patient's treatment or management. In this case, providing a referral to a social worker is a specific plan of action to address the patient's needs beyond medical treatment. Choices A, C, and D provide information about the patient's current condition or symptoms, which would typically be recorded in the 'assessment' or 'subjective' portions of the clinical record.
Question 2 of 5
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). Which score indicates a moderate head injury?
Correct Answer: B
Rationale: The correct answer is B (9-12) because a GCS score of 9-12 indicates a moderate head injury. This score reflects a patient who is moderately impaired in terms of consciousness and neurological functioning. A GCS score of 13-15 (choice A) indicates mild injury, while a score of 6-8 (choice C) indicates severe injury. A score of 3-5 (choice D) indicates a critical and severe head injury, typically associated with deep coma. In summary, the GCS score of 9-12 represents a moderate head injury, while the other choices reflect different levels of severity in head injuries based on the Glasgow Coma Scale.
Question 3 of 5
The nurse is performing a cranial nerve assessment and asks the patient to smile. Which cranial nerve is being tested?
Correct Answer: A
Rationale: The correct answer is A: Cranial nerve VII (facial nerve). When the nurse asks the patient to smile, they are assessing the function of the facial muscles, which is innervated by cranial nerve VII. This nerve controls facial expression, including smiling. Cranial nerve V (trigeminal nerve) is responsible for sensation in the face and chewing, not facial expression. Cranial nerve IX (glossopharyngeal nerve) is involved in swallowing and taste, not facial movement. Cranial nerve X (vagus nerve) controls various autonomic functions like heart rate and digestion, not facial muscles.
Question 4 of 5
The nurse is performing a physical assessment and notes that the patient has unilateral leg swelling. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). Unilateral leg swelling is a common symptom of DVT, which is a blood clot in the deep veins of the leg. The swelling occurs due to impaired blood flow caused by the clot. It is important to consider DVT as it can lead to serious complications like pulmonary embolism. Incorrect choices: B: Congestive heart failure typically presents with bilateral leg swelling due to fluid retention. C: Peripheral artery disease usually manifests with symptoms like leg pain while walking, not necessarily swelling. D: Chronic venous insufficiency results in long-standing venous hypertension leading to skin changes like ulcers, not acute unilateral swelling.
Question 5 of 5
The nurse is performing a neurological assessment and asks the patient to squeeze their hands. Which of the following is being tested?
Correct Answer: B
Rationale: The correct answer is B: Motor function and strength. When the nurse asks the patient to squeeze their hands, they are assessing the patient's ability to generate force through muscle contractions, which tests motor function and strength. This action primarily involves the upper extremity muscles and requires intact nerve pathways from the brain to the muscles. Incorrect Choices: A: Cerebellar function is responsible for coordination, balance, and muscle tone, not squeezing hands. C: Sensory function involves detecting stimuli like touch, pain, temperature, and vibration, which are not directly tested by squeezing hands. D: Coordination is tested through tasks requiring precise movements and smooth performance, such as finger-to-nose or heel-to-shin tests, not squeezing hands.