ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 36-year-old teacher presents with sharp, knifelike pain on the left side of her chest for 2 days. Breathing and lying down make the pain worse, while sitting forward helps. A scratching noise is heard at the lower left sternal border, coincident with systole.
Correct Answer: B
Rationale: The correct answer is B: Pericarditis. The key findings in this scenario are sharp chest pain worsened by breathing and lying down but improved by sitting forward, which is characteristic of pericarditis. The scratching noise heard at the lower left sternal border during systole is known as a pericardial friction rub, a classic sign of pericarditis. Angina pectoris typically presents as chest discomfort or pressure that is relieved by rest, nitroglycerin, or both. Dissecting aortic aneurysm usually presents with severe, tearing chest pain that may radiate to the back. Pleural pain is typically sharp and worsened by coughing or deep breathing, not necessarily positional like in this case.
Question 2 of 5
During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
Correct Answer: A
Rationale: The correct answer is A because a hallucination is a false sensory perception that does not correspond to reality. In this scenario, the man hearing his dead wife talking is an example of an auditory hallucination. This is a perception without any external stimuli. Choice B is incorrect because hearing the doorbell ring is a normal auditory perception, even if no one is actually there. Choice C is incorrect as seeing a man standing in the closet is an example of an illusion, not a hallucination, as the child's perception changes when the lights are turned on. Choice D is incorrect because mistaking a dog for a blanket is a misinterpretation of a real object, not a hallucination.
Question 3 of 5
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
Correct Answer: D
Rationale: The correct answer is D: Uncomfortable talking about his son's treatment. The sudden change in posture to a closed position (crossed arms and legs) signifies defensiveness or discomfort, possibly indicating emotional distress or difficulty discussing the topic. This nonverbal cue suggests a shift from openness to a protective stance, reflecting a potential reluctance or unease with the conversation. Choices A and B are incorrect as the change in posture was not simply for comfort or adjustment. Choice C is incorrect as there is no direct indication of tiredness or need for a break.
Question 4 of 5
During a physical examination, which action is most important for preventing infection?
Correct Answer: B
Rationale: The correct answer is B: Washing hands before and after patient contact. This is crucial for preventing infection as it reduces the spread of pathogens. Washing hands removes dirt and microbes that may be present on the hands, preventing their transfer to the patient or from the patient to the healthcare provider. Wearing gloves (choice A) is important but should not replace proper handwashing. Disinfecting equipment (choice C) is essential but not as critical as hand hygiene. Avoiding contact with the patient's skin (choice D) is unrealistic and not practical in a physical examination.
Question 5 of 5
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
Correct Answer: C
Rationale: The correct technique for measuring chest circumference in infants is at the nipple line, as this is the standard anatomical landmark for consistency. Measuring at this point ensures accurate and reliable data for growth monitoring. Measuring the length of an infant with a tape measure (choice A) is correct for assessing height. Weighing the infant on an electronic standing scale (choice B) is appropriate for measuring weight. Measuring head circumference by wrapping the tape measure over the nose and cheekbones (choice D) is incorrect, as it can lead to inaccurate measurements.