ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 28-year-old woman presents with a complaint of chronic headaches that are worse in the morning and are associated with nausea and vomiting. She also reports blurred vision. Neurological examination reveals papilledema. What is the most likely diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Intracranial hypertension. This condition presents with chronic headaches that are worse in the morning, associated with nausea, vomiting, blurred vision, and papilledema on neurological examination. The increased intracranial pressure causes these symptoms. Migraine (A), cluster headache (B), and tension-type headache (C) typically do not present with papilledema or blurred vision.
Question 2 of 5
A 70-year-old man presents with a complaint of severe, crushing chest pain that radiates to his left arm. He has a history of hypertension and diabetes mellitus. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Myocardial infarction. Given the patient's age, risk factors (hypertension, diabetes), and symptoms (severe chest pain radiating to left arm), myocardial infarction is the most likely diagnosis. In myocardial infarction, there is a blockage of blood flow to the heart muscle leading to tissue damage. Angina (choice A) is similar but is usually relieved by rest or medication. Aortic dissection (choice C) presents with sudden, severe chest or back pain. Pulmonary embolism (choice D) typically presents with sudden shortness of breath and chest pain worsened by breathing.
Question 3 of 5
The nurse is assessing a patient's peripheral pulses and notes that the pulse is weak and thready. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Hypovolemia. Weak and thready pulses are indicative of decreased blood volume, which is a characteristic of hypovolemia. When there is not enough blood circulating in the body, peripheral pulses may become weak and difficult to palpate. Other choices are incorrect because: B: Hypervolemia would typically present with bounding pulses due to excess fluid volume. C: Arterial occlusion would result in absent or diminished pulses, not weak and thready pulses. D: Peripheral edema would not directly affect the strength or quality of peripheral pulses.
Question 4 of 5
The nurse is performing an abdominal examination and notes that the patient has tympany over the entire abdomen. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Gas-filled intestines. Tympany over the entire abdomen indicates the presence of gas, which produces a resonant, drum-like sound upon percussion. This finding is characteristic of gas-filled intestines. Abdominal obstruction (A) would present with localized tympany and possibly a tympanic or dull sound in the affected area. Ascites (B) would result in dullness upon percussion due to fluid accumulation in the abdomen. Liver enlargement (D) would also lead to dullness upon percussion over the liver area, rather than tympany over the entire abdomen.
Question 5 of 5
During a cardiovascular assessment, the nurse notes that the patient has a jugular vein distension (JVD) when positioned at 45 degrees. What does this finding suggest?
Correct Answer: C
Rationale: The correct answer is C: Right-sided heart failure. Jugular vein distension (JVD) at 45 degrees indicates increased central venous pressure, commonly seen in right-sided heart failure. In this condition, the weakened right heart is unable to pump effectively, leading to venous congestion and JVD. Dehydration (B) typically presents with decreased jugular venous pressure. Pulmonary embolism (D) may cause JVD, but it's usually accompanied by other symptoms. JVD is not a normal finding (A) at 45 degrees and suggests an underlying pathology.