ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
Which physical assessment finding is most indicative of fluid volume overload?
Correct Answer: C
Rationale: The correct answer is C: Peripheral edema. Peripheral edema is the accumulation of fluid in the extremities, indicating fluid volume overload. This is due to increased hydrostatic pressure in the capillaries. Dry mucous membranes (A) suggest dehydration, decreased skin turgor (B) is also a sign of dehydration, and postural hypotension (D) is often associated with hypovolemia. Peripheral edema is the most specific finding for fluid volume overload as it directly reflects an excess of fluid in the body.
Question 2 of 5
The nurse is assessing a patient's hearing using the Weber test. How is this test performed?
Correct Answer: B
Rationale: The correct answer is B because the Weber test is performed by striking a tuning fork and placing it on the patient's forehead. This causes vibrations that are conducted through the skull to both cochleas. In a normal hearing individual, the sound will be heard equally in both ears. If there is unilateral conductive hearing loss, the sound will be louder in the affected ear, and if there is unilateral sensorineural hearing loss, the sound will be louder in the unaffected ear. Choice A is incorrect because the Weber test does not involve whispering words for the patient to repeat. Choice C is incorrect because it describes the Rinne test, not the Weber test. Choice D is incorrect because it does not involve identifying different tones, but rather assessing for lateralization of sound.
Question 3 of 5
During an eye assessment, the nurse observes that the patient's pupils constrict when focusing on a near object. What is this response called?
Correct Answer: A
Rationale: Accommodation is the correct answer because it refers to the ability of the eye to adjust its focus when moving between objects at different distances. When the pupils constrict while focusing on a near object, it indicates the eye is accommodating to improve clarity for close-up vision. Convergence (B) is the coordinated movement of both eyes towards a near object, not pupil constriction. Refraction (C) is the bending of light as it passes through the eye, not the pupil's response. Visual acuity (D) is the sharpness of vision, not related to pupil constriction during accommodation.
Question 4 of 5
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. Which component is not included in this scale?
Correct Answer: D
Rationale: The correct answer is D: Pupil size. The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, motor response, and verbal response. Pupil size is not included in the GCS as it focuses on assessing the patient's neurological status and responsiveness to stimuli. Pupil size is typically assessed separately as part of a neurologic examination but is not a component of the GCS. Therefore, D is the correct answer. A, B, and C are incorrect because they are the three components (eye opening, motor response, verbal response) included in the Glasgow Coma Scale.
Question 5 of 5
The nurse is assessing a patient's respiratory system and notes the presence of stridor. What does this finding most likely indicate?
Correct Answer: B
Rationale: The presence of stridor indicates upper airway obstruction. Stridor is a high-pitched, inspiratory sound that occurs when there is partial obstruction in the upper airway, typically in the larynx or trachea. This sound is produced as air passes through a narrowed or partially blocked airway during inhalation. Lower airway obstruction (Choice A) typically presents with wheezing, not stridor. Pleural effusion (Choice C) is the accumulation of fluid in the pleural space, which would not cause stridor. Pulmonary edema (Choice D) is the accumulation of fluid in the lungs, leading to crackles on auscultation, not stridor.