ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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 2 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 3 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.
Question 4 of 5
During a musculoskeletal assessment, the nurse notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. In rheumatoid arthritis, patients typically present with tender, swollen joints and decreased range of motion due to joint inflammation and synovial thickening. This autoimmune condition affects multiple joints symmetrically. Osteoarthritis (A) is characterized by joint pain and stiffness, but not usually significant swelling or systemic symptoms like in rheumatoid arthritis. Gout (C) is characterized by sudden, severe pain, redness, and swelling, typically affecting one joint, often the big toe. Bursitis (D) is inflammation of the bursae sacs, causing localized pain and swelling, but not typically associated with significant joint stiffness or systemic symptoms as in rheumatoid arthritis.
Question 5 of 5
Core body temperature is ___ surface body temperature.
Correct Answer: B
Rationale: Higher than, is correct because core body temperature (e.g., rectal, tympanic) is typically 0.5°F-1°F higher than surface temperature (e.g., oral, axillary) due to proximity to internal organs and less environmental influence. Core sites reflect true metabolic heat, averaging 98.6°F-100.4°F, while surface sites like skin average 97°F-99°F. Less than, reverses this fact. Equal to, ignores the gradient. None of the above, dismisses the clear difference. This distinction is vital in nursinge.g., rectal readings are higher and more stable than axillary, guiding fever assessment. Physiological principles and clinical tools (e.g., thermometers) confirm B as the correct answer.