ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Which of the following examples includes information recorded in the 'assessment' portion of the clinical record?
Correct Answer: D
Rationale: The correct answer is D because tenderness in the right upper quadrant is a specific clinical finding that would typically be recorded in the 'assessment' portion of the clinical record. This information is objective and related to a physical examination finding, which is crucial for assessing the patient's condition. A, B, and C are incorrect because they are subjective observations or general statements that do not provide specific clinical assessment information. Option A describes the patient's overall appearance, B relates to the patient's subjective feeling, and C provides a vital sign measurement, all of which would typically be recorded in the 'subjective' or 'objective' portions of the clinical record.
Question 2 of 5
The nurse is auscultating the abdomen and hears high-pitched, tinkling sounds. What does this finding most likely indicate?
Correct Answer: C
Rationale: The high-pitched, tinkling sounds heard during auscultation of the abdomen indicate bowel obstruction. This is due to the increased peristalsis and fluid and gas moving through the obstructed bowel, causing the tinkling noise. Normal peristalsis (choice A) would not produce such sounds. Gastrointestinal reflux (choice B) is associated with heartburn and regurgitation, not tinkling sounds. Ascites (choice D) is the accumulation of fluid in the peritoneal cavity and would not produce the described tinkling sounds. In summary, the tinkling sounds suggest bowel obstruction due to increased peristalsis and fluid and gas movement, making choice C the correct answer.
Question 3 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 4 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 5 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.