ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 70-year-old man with a history of hypertension presents with shortness of breath and orthopnea. His physical examination reveals bilateral pedal edema, crackles at the lung bases, and jugular venous distention. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Congestive heart failure. This diagnosis is likely due to the patient's history of hypertension, presenting symptoms of shortness of breath, orthopnea, bilateral pedal edema, crackles at lung bases, and jugular venous distention. These findings are classic signs of congestive heart failure, indicating impaired heart function leading to fluid accumulation in the lungs and peripheral tissues. Chronic obstructive pulmonary disease (choice A) typically presents with a history of smoking, productive cough, and wheezing, not consistent with this patient's presentation. Pulmonary embolism (choice C) would present with sudden onset dyspnea and chest pain, not gradual symptoms as seen here. Renal failure (choice D) can cause fluid retention, but the combination of symptoms and signs in this patient points more towards congestive heart failure.
Question 2 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 3 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 4 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 5 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.