ATI RN
Assess Vital Signs Rationale Questions
Question 1 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 2 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.
Question 3 of 5
During a cardiac assessment, the nurse notes a high-pitched, scratchy sound heard during both systole and diastole. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: Pericardial friction rub, as it is a high-pitched, scratchy sound heard during both systole and diastole, indicating inflammation of the pericardium. This sound is produced by the rubbing of inflamed pericardial layers during the cardiac cycle. B: Aortic stenosis produces a systolic murmur. C: Mitral valve regurgitation produces a holosystolic murmur. D: Heart murmur is a generic term and does not specifically describe the high-pitched, scratchy sound heard during both systole and diastole.
Question 4 of 5
A 50-year-old woman presents with a complaint of severe headaches that occur in the morning and are associated with nausea and vomiting. She also reports blurred vision. Neurological examination reveals papilledema. Which of the following is the most likely diagnosis?
Correct Answer: D
Rationale: The correct answer is D, Intracranial hypertension. This condition is characterized by increased pressure within the skull, leading to symptoms such as morning headaches, nausea, vomiting, blurred vision, and papilledema. The patient's presentation of severe morning headaches with associated symptoms and papilledema is classic for intracranial hypertension. Migraine (A) typically presents with pulsating headaches without neurological signs. Cluster headache (B) is characterized by severe unilateral headaches with autonomic features but not typically associated with papilledema. Tension-type headache (C) is usually bilateral, mild to moderate in intensity, and not associated with papilledema. In summary, the patient's symptoms and signs are most consistent with intracranial hypertension due to the presence of morning headaches, nausea, vomiting, blurred vision, and papilledema.
Question 5 of 5
A 40-year-old man presents with a complaint of fatigue, weight loss, and night sweats. He has a history of smoking and a chronic cough. Chest X-ray reveals a mass in the left upper lobe. What is the most likely diagnosis?
Correct Answer: C
Rationale: The most likely diagnosis for the 40-year-old man with fatigue, weight loss, chronic cough, and a mass in the left upper lobe on chest X-ray is lung cancer (Choice C). 1. Symptoms: Fatigue, weight loss, night sweats are common in lung cancer due to systemic effects. 2. History: Smoking and chronic cough are major risk factors for lung cancer. 3. Imaging: Presence of a mass in the left upper lobe on chest X-ray is highly suggestive of lung cancer. 4. Exclusion: Pneumonia (Choice A) typically presents with fever and productive cough, not weight loss. Tuberculosis (Choice B) may show upper lobe involvement but is less common in non-endemic areas without known exposure. Chronic obstructive pulmonary disease (Choice D) does not typically present with weight loss or night sweats.