ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) 3+. Bounding pulses indicate a significant increase in the strength and amplitude of the pulse, often associated with conditions like peripheral vascular disease. This strength is graded on a scale from 0 to 3, with 3+ representing the highest intensity or bounding pulse. Option A) 0 is incorrect because it indicates an absent pulse, which is not the case in this scenario. Options C) 2+ and D) 1+ both represent pulses with varying degrees of strength, but they do not accurately describe the bounding nature of the pulses seen in peripheral vascular disease. Educationally, understanding how to assess and interpret pulses is crucial for healthcare providers, especially in patients with underlying cardiovascular conditions. Recognizing bounding pulses can provide valuable diagnostic information and guide appropriate interventions for the patient's care. It is essential for healthcare professionals to be proficient in assessing vital signs and recognizing abnormalities to provide optimal patient care.
Question 2 of 5
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
Correct Answer: C
Rationale: The correct answer is C) A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the best choice for the RN floated from the medical unit because they require timely administration of antibiotics for their bacterial meningitis. This task aligns closely with the medical unit's scope of practice, as administering medications is a common nursing responsibility in that setting. Option A) involves a patient with a basilar skull fracture and clear drainage, which may require neurologic assessments and interventions beyond the typical scope of a medical unit RN. Option B) presents a patient with a ruptured berry aneurysm, a complex neurologic condition that necessitates specialized care and monitoring. Option D) features a patient with an astrocytoma post-craniotomy, requiring neurologic surveillance and expertise that exceed the capabilities of a medical unit RN. By selecting option C, the RN from the medical unit can effectively contribute to the care of a patient needing medication administration, a task well within their competency level. This scenario provides a valuable educational context by highlighting the importance of aligning nursing assignments with staff competencies to ensure safe and effective patient care.
Question 3 of 5
A client admitted to the hospital with a neurological problem requires magnetic resonance imaging. The nurse understands that the client may be ineligible for this diagnostic procedure based on the client's history of:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Prosthetic valve replacement. The reason for this is that individuals with certain metallic implants or devices, such as prosthetic heart valves, pacemakers, or other metallic objects in their bodies, may not be eligible for magnetic resonance imaging (MRI) due to the risk of interference with the magnetic field of the machine. Option A) Hypertension, Option B) Heart failure, and Option D) Chronic obstructive pulmonary disorder do not typically preclude a patient from undergoing an MRI procedure. Hypertension, heart failure, and COPD are common health conditions that are not contraindications for MRI. Educationally, this question highlights the importance of understanding contraindications to specific diagnostic procedures based on a patient's medical history. Nurses need to be aware of these contraindications to ensure patient safety and the accuracy of diagnostic tests. This knowledge helps in providing optimal care and preventing potential risks or complications for patients undergoing medical procedures.
Question 4 of 5
A physical therapist assesses the functional strength of a patient's hip extensors while observing the patient move from standing to sitting. What type of contraction occurs in the hip extensors during this activity?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) eccentric contraction. When a patient moves from standing to sitting, the hip extensors are lengthening while controlling the descent, which is characteristic of an eccentric contraction. An eccentric contraction occurs when a muscle lengthens under load, providing controlled movement and deceleration. In the case of the hip extensors during the described activity, they are contracting eccentrically to support the patient's lowering to a seated position. Now, let's address why the other options are incorrect: A) Concentric contraction involves a muscle shortening while generating force. This is not the case when the hip extensors are controlling the descent from standing to sitting. C) Isometric contraction occurs when a muscle generates force without changing in length. In this scenario, the hip extensors are definitely changing length during the movement. D) Isokinetic contraction involves a constant speed of contraction, which is not specifically indicated in the described activity of moving from standing to sitting. Understanding the type of muscle contraction involved in various movements is crucial for healthcare professionals like physical therapists to assess functional strength accurately and design appropriate rehabilitation programs. Knowledge of different contraction types helps in tailoring exercises to improve strength, mobility, and overall function effectively.
Question 5 of 5
A physical therapist observes the gait of a patient rehabilitating from a traumatic brain injury. The patient has significant spasticity in the lower extremities and demonstrates a scissoring gait pattern. The MOST likely cause of the gait deviation is increased tone in the:
Correct Answer: A
Rationale: The correct answer is A) hip adductors. In a scissoring gait pattern, the legs cross midline due to increased tone in the hip adductors, causing them to pull the legs towards each other during walking. This results in a narrow-based, stiff-legged gait characteristic of spasticity. Option B) hip abductors would actually help to counteract the adduction and prevent the legs from crossing over excessively. Option C) knee flexors and Option D) ankle dorsiflexors are not primarily responsible for the scissoring gait seen in this patient. Educationally, understanding gait deviations related to spasticity is crucial for healthcare professionals like physical therapists to effectively assess and treat patients with neurological conditions. Recognizing the specific muscle groups involved in abnormal gait patterns can guide interventions aimed at improving mobility and quality of life for patients undergoing rehabilitation.