ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
Which physical assessment finding is most consistent with dehydration?
Correct Answer: C
Rationale: The correct answer is C: Dry, cracked lips. Dehydration leads to decreased fluid volume in the body, causing dryness and cracking of the lips due to lack of moisture. Moist mucous membranes (choice A) are typically seen in hydrated individuals. Increased skin turgor (choice B) is a sign of dehydration, but dry, cracked lips are more specific. Bounding peripheral pulses (choice D) are associated with conditions like fluid overload or increased blood volume, not dehydration. Dry, cracked lips are a key indicator of dehydration due to the direct impact of fluid depletion on mucous membranes.
Question 2 of 5
During a pain assessment, the patient rates their pain as 8 on a scale of 0 to 10. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Administer prescribed pain medication. The priority action is to address the patient's pain to provide relief and improve comfort. Administering pain medication is essential to manage the patient's pain effectively. Reassessing the pain in 30 minutes (choice A) delays pain relief. Simply documenting the pain level as reported (choice C) without taking action does not address the patient's immediate needs. Applying a warm compress (choice D) may provide some comfort but does not directly address the pain intensity reported by the patient. Administering pain medication is the most appropriate and immediate action to address the patient's discomfort.
Question 3 of 5
The nurse is performing a cardiac assessment and hears a harsh, grating sound during both systole and diastole. What does this sound most likely indicate?
Correct Answer: C
Rationale: The correct answer is C: Pericardial friction rub. This sound is typically indicative of inflammation of the pericardial sac, causing the pericardial layers to rub against each other during both systole and diastole. This is a distinctive sound separate from murmurs. A and B are incorrect as they refer to murmurs which are typically heard during either systole (A) or diastole (B). D, mitral valve prolapse, would present with a mid-systolic click and late systolic murmur, not a continuous sound throughout the cardiac cycle like a pericardial friction rub.
Question 4 of 5
During a respiratory assessment, the nurse notes that the patient is using their accessory muscles to breathe. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Acute asthma exacerbation. When a patient is using accessory muscles to breathe, it indicates respiratory distress. In acute asthma exacerbation, airway constriction leads to difficulty breathing, causing the patient to use accessory muscles to aid in breathing. This is a characteristic feature of asthma exacerbation. Summary: - B: COPD is characterized by chronic airflow limitation, not typically associated with sudden use of accessory muscles. - C: Pneumothorax is a collapsed lung, which may cause shortness of breath but doesn't usually result in the use of accessory muscles. - D: Pulmonary embolism is a blockage in a pulmonary artery, which can lead to shortness of breath but doesn't typically cause the use of accessory muscles for breathing.
Question 5 of 5
During a neurological assessment, the nurse asks the patient to close their eyes and identify familiar objects. Which sensory function is being tested?
Correct Answer: D
Rationale: The correct answer is D: Stereognosis. This test assesses the patient's ability to identify familiar objects through touch and manipulation without visual cues. It specifically evaluates the integration of tactile, proprioceptive, and sensorimotor functions in the brain. The other options are incorrect because: A: Pain sensation is typically assessed using a pinprick test. B: Proprioception is evaluated through tests involving joint position sense and movement. C: Light touch sensation is tested by using a cotton wisp or a gentle touch stimulus.