ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A 60-year-old woman presents with complaints of difficulty swallowing and weight loss. On examination, she has a palpable mass in the left upper abdomen. What is the most likely diagnosis?
Correct Answer: A
Rationale: The most likely diagnosis for a 60-year-old woman with difficulty swallowing, weight loss, and a palpable mass in the left upper abdomen is pancreatic cancer. Difficulty swallowing can be indicative of compression of the esophagus by the mass. Weight loss is common in pancreatic cancer due to malabsorption and cancer cachexia. A palpable mass in the left upper abdomen corresponds to the location of the pancreas. Pancreatic cancer commonly presents with these symptoms and signs. Gastric ulcer (B) typically presents with abdominal pain, bloating, and nausea. Cirrhosis (C) usually presents with symptoms related to liver dysfunction such as jaundice and ascites. Cholecystitis (D) presents with right upper quadrant abdominal pain, nausea, and vomiting.
Question 2 of 5
The nurse is assessing a patient's abdomen and notes the presence of visible peristalsis. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Gastrointestinal obstruction. Visible peristalsis indicates increased movement of the intestines in an attempt to overcome the obstruction. This finding is not associated with normal digestive function (choice A), ascites (choice C), or hernia (choice D). Gastrointestinal obstruction leads to visible peristalsis due to the intestines trying to push contents past the blockage. This assessment finding is crucial for prompt intervention to prevent complications.
Question 3 of 5
The nurse is assessing a patient's abdomen and detects a mass. What is the next step in the assessment?
Correct Answer: C
Rationale: The correct next step in assessing a detected abdominal mass is to palpate it for size and consistency. Palpation helps determine the characteristics of the mass, such as its shape, size, texture, and tenderness. This step provides crucial information for further evaluation and diagnosis. Auscultation for bowel sounds would not provide direct information about the mass. Percussion for tenderness may be uncomfortable and should be done after palpation. Referring the patient for imaging should come after a thorough physical examination and initial assessment of the mass.
Question 4 of 5
The nurse is performing an abdominal examination and detects a bruit over the aorta. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The presence of a bruit over the aorta during an abdominal examination is most likely associated with an Aortic Aneurysm. Aneurysms can cause turbulent blood flow resulting in a bruit. Aortic aneurysm is a common location for this finding due to the dilation of the aorta. Renal artery stenosis, pneumonia, and pancreatitis are not typically associated with a bruit over the aorta, making them incorrect choices.
Question 5 of 5
The nurse is assessing a patient's lungs and hears a harsh, grating sound during both inspiration and expiration. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Pleural friction rub. This sound occurs due to the rubbing together of inflamed pleural surfaces during both inspiration and expiration. It is typically heard in conditions such as pleurisy or pneumonia. Rhonchi (B) are low-pitched rattling sounds typically heard during expiration, wheezing (C) is a high-pitched musical sound heard during expiration, and pneumothorax (D) presents with decreased or absent breath sounds on the affected side, not a friction rub.