ATI RN
Vital Signs Assessment Questions
Question 1 of 5
Which of the following is consistent with obturator sign?
Correct Answer: B
Rationale: The obturator sign is a test for appendicitis. B is correct because it describes the characteristic pain felt in the right hypogastric region when the right hip and knee are flexed and internally rotated, indicating irritation of the obturator muscle due to an inflamed appendix. A is incorrect as it describes rebound tenderness in a different location. C is incorrect as it describes pain with thigh extension or flexion, not internal rotation. D is incorrect as it describes pain that affects breathing, not related to obturator muscle irritation.
Question 2 of 5
A client is having a lumbar puncture performed. The nurse would plan to place the client in which position?
Correct Answer: D
Rationale: The correct answer is D. During a lumbar puncture, the client should be positioned in a side-lying position with the legs pulled up and head bent down onto the chest. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to access the lumbar area. Placing the legs up also helps to widen the spaces between the vertebrae, making it easier to insert the needle without damaging the spinal cord. The head bent down onto the chest helps to round the back, further increasing the space between the vertebrae. Choice A is incorrect because placing a pillow under the hip does not provide the necessary positioning for a lumbar puncture. Choice B is incorrect as the prone position with a pillow under the abdomen would not facilitate access to the lumbar area. Choice C is incorrect as the Trendelenburg's position is not recommended for lumbar punctures as it can increase intracranial pressure.
Question 3 of 5
During a neurological assessment, the nurse tests cranial nerve VII. What is the primary function of this nerve?
Correct Answer: B
Rationale: The correct answer is B: Facial movements and expression. Cranial nerve VII, also known as the facial nerve, primarily controls facial muscles responsible for facial expressions, such as smiling and frowning. It also innervates the muscles involved in closing the eyes and controlling the forehead and mouth movements. Other choices are incorrect because cranial nerve VII is not primarily responsible for hearing and balance (A), swallowing and speech (C), or eye movement (D). The key function of cranial nerve VII lies in its role in facial movements and expressions.
Question 4 of 5
Which of the following findings is most concerning during a peripheral vascular assessment?
Correct Answer: C
Rationale: The correct answer is C, unilateral edema. This finding is most concerning as it may indicate a blockage or dysfunction in the lymphatic or venous system, potentially leading to serious conditions like deep vein thrombosis. In contrast, A and D are normal findings indicating good peripheral circulation, while B is also normal and indicates balanced blood flow.
Question 5 of 5
During a skin assessment, the nurse notes a lesion with irregular borders and varied colors. What is the next action?
Correct Answer: B
Rationale: The correct answer is B: Refer the patient for further evaluation. This is because the lesion with irregular borders and varied colors raises concern for possible skin cancer. Referring the patient for further evaluation by a dermatologist is crucial to determine the nature of the lesion and initiate appropriate treatment. Documenting it as a normal finding (choice A) is incorrect as it may delay necessary intervention. Applying an antibiotic ointment (choice C) is not indicated as the lesion is not suggestive of infection. Reassessing the lesion in one month (choice D) could lead to a delay in diagnosis and treatment if the lesion is indeed malignant.