ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign vascular growths that appear as small, bright red dots on the skin, often found in older individuals. In this case, the patient is a 42-year-old woman, which fits the age range for senile angiomas. Anasarca (A) is generalized edema, not related to the described skin findings. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not typically presenting as bright red dots. Latent myeloma (D) is a type of blood cancer and not associated with the described skin lesions.
Question 2 of 5
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?
Correct Answer: B
Rationale: The correct answer is B because bloody or clear watery drainage can indicate a basal skull fracture, which is a serious complication of head injuries. Assessing for this type of drainage is crucial as it may signify a potentially life-threatening condition that requires immediate medical attention. A: Incorrect. Purulent drainage resulting from a ruptured eardrum is concerning but not as immediately life-threatening as a basal skull fracture. C: Incorrect. Increased cerumen occluding the auditory canal is not as urgent as identifying a basal skull fracture. D: Incorrect. While foreign bodies in the ear canal are important to assess, they are not as critical as identifying a basal skull fracture.
Question 3 of 5
The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:
Correct Answer: A
Rationale: Step-by-step rationale for Answer A: 1. Leukoedema is a common benign condition characterized by grayish-white lesions in the mouth. 2. It is more prevalent in dark-skinned individuals, like Black patients. 3. The lesion described matches the characteristics of leukoedema - nontender, grayish-white, and common in dark-pigmented individuals. 4. Therefore, the correct answer is A. Summary of why other choices are incorrect: B: Hyperpigmentation does not present as grayish-white lesions and is not normal in this context. C: Torus palatinus is a bony growth on the roof of the mouth, not a lesion on the buccal mucosa. D: Cancerous lesions usually have different characteristics and require further evaluation beyond a visual assessment.
Question 4 of 5
A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?
Correct Answer: D
Rationale: The correct answer is D. A sucking tubercle is a normal finding in infants caused by the friction of breastfeeding or bottle-feeding. It typically appears as a fleshy, elevated area on the upper lip and does not require any intervention as it resolves on its own. This explanation reassures the mother that the infant's condition is benign and does not pose any health concerns. Choice A is incorrect because the irritation is not related to teething. Choice B is incorrect as the finding is a normal variant and does not require further evaluation. Choice C is incorrect as chronic drooling does not typically cause a fleshy, elevated area on the upper lip.
Question 5 of 5
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
Correct Answer: D
Rationale: The correct answer is D: Increased density of lung tissue. A dull percussion note over a lung lobe indicates increased density of the underlying tissue, which can be due to conditions like pneumonia, atelectasis, or pulmonary fibrosis. Shallow breathing (A) would not directly cause a dull percussion note. Normal lung tissue (B) would produce a resonant percussion note. Decreased adipose tissue (C) does not influence the percussion note over the lung. Therefore, the increased density of lung tissue (D) is the most likely cause for a dull percussion note.