ATI LPN
Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 21 : Physical Assessment Questions
Question 1 of 5
If you hear a shrill, high-pitched, crowing sound coming from the room of a 3-year-old child who has croup, you recognize the ominous sign known as
Correct Answer: E
Rationale: Stridor is a high-pitched, crowing sound associated with upper airway obstruction, common in croup.
Question 2 of 5
At which of the following locations can you best hear the sound of the aortic valve?
Correct Answer: C
Rationale: The aortic valve is best heard at the right 2nd intercostal space near the sternum.
Question 3 of 5
The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this?
Correct Answer: B
Rationale: Auscultating the apical pulse for 60 seconds provides the most accurate heart rate, especially for irregular rhythms.
Question 4 of 5
You know that when assessing the pulse there is more than one characteristic you should assess. Which of the following best identifies the characteristics you must assess?
Correct Answer: A
Rationale: Pulse assessment includes rate (beats per minute), Rhythm (regular or irregular), and strength (force of the pulse).
Question 5 of 5
You are caring for a patient with mitral valve stenosis. You plan to assess the mitral valve during your initial assessment. Where will you be best able to auscultate the mitral valve?
Correct Answer: C
Rationale: The mitral valve is best heard at the apex of the left ventricle, typically in the 5th intercostal space, midclavicular line.