ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
You are assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the patient's pain make you concerned for this disease process?
Correct Answer: C
Rationale: The correct answer is C: Calf. Atherosclerosis in the lower extremities typically presents as intermittent claudication, which is characterized by pain, cramping, or fatigue in the calf muscles during physical activity. This occurs due to insufficient blood flow to the muscles affected by the narrowed arteries. Pain in the thigh (A), knee (B), or ankle (D) would not be as specific for atherosclerosis in the lower extremities, as the calf is the most common site for this condition.
Question 2 of 5
Which of the following assessments is most indicative of adequate peripheral circulation?
Correct Answer: B
Rationale: The correct answer is B: Capillary refill time less than 2 seconds. This assessment is indicative of adequate peripheral circulation because it measures how quickly blood refills in the capillaries after they have been compressed. A capillary refill time of less than 2 seconds indicates normal circulation, as it demonstrates that blood is flowing efficiently to the extremities. Rationale: A: Pallor in the extremities indicates poor circulation and reduced blood flow, which is not indicative of adequate peripheral circulation. C: Cool skin temperature in the lower extremities suggests vasoconstriction and reduced blood flow, not adequate circulation. D: Diminished dorsalis pedis pulse indicates a weak or absent pulse in the foot, which is a sign of impaired circulation and not indicative of adequate peripheral circulation.
Question 3 of 5
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
Correct Answer: B
Rationale: The correct answer is B: Nail bed pressure. This is the appropriate method to test the client's peripheral response to pain in an unconscious state. Applying pressure to the nail bed can elicit a localized pain response, indicating intact peripheral nerve function. Rationale: 1. Nail bed pressure is a sensitive area that can evoke a pain response if the client has intact peripheral nerve function. 2. Sternal rub (A) is a sternal pressure technique used to arouse a client, not specifically to test peripheral response. 3. Pressure on the orbital rim (C) is not appropriate for testing peripheral response and can be harmful. 4. Squeezing the sternocleidomastoid muscle (D) is a method to assess cranial nerve XI function, not peripheral response to pain.
Question 4 of 5
A patient recently admitted to an acute care hospital is referred to physical therapy. The physical therapist documents the following clinical signs: pallor, cyanosis, and cool skin. These clinical signs are MOST consistent with:
Correct Answer: B
Rationale: The clinical signs of pallor, cyanosis, and cool skin are indicative of poor oxygenation and circulation, which are commonly seen in anemia. Anemia leads to reduced oxygen-carrying capacity, resulting in pallor and cyanosis. Cool skin is a result of decreased blood flow. Cor pulmonale is related to right heart failure due to lung disease, not directly related to the signs described. Hypertension typically presents with elevated blood pressure, not the signs mentioned. Diaphoresis refers to excessive sweating, which is not associated with the described clinical signs. Therefore, the correct answer is B (anemia) based on the patient's presentation.
Question 5 of 5
A physical therapist reviews the medical record of a patient diagnosed with Parkinson's disease. Which clinical finding would the therapist MOST likely observe?
Correct Answer: A
Rationale: The correct answer is A: Hypertonicity. In Parkinson's disease, there is a loss of dopamine-producing cells, leading to increased muscle tone or hypertonicity. This results in stiffness and rigidity of muscles, making movements slow and difficult. Hypotonicity (B) refers to decreased muscle tone and is not typically seen in Parkinson's. Hyperreflexia (C) is an exaggerated reflex response, which is not a common feature of Parkinson's. Hyporeflexia (D) is reduced reflex response, which is not typically associated with Parkinson's disease. Hence, the most likely clinical finding in a patient with Parkinson's disease would be hypertonicity.