ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
Correct Answer: A
Rationale: The correct answer is A. In a severe exacerbation of heart failure, the patient is likely to exhibit symptoms such as shortness of breath, orthopnea (difficulty breathing lying flat), paroxysmal nocturnal dyspnea (sudden onset of difficulty breathing at night), and ankle edema (swelling). These symptoms are classic signs of heart failure exacerbation due to fluid overload and poor cardiac function. Explanation for why the other choices are incorrect: - B: Rasping cough, thick mucoid sputum, wheezing, and bronchitis are more indicative of respiratory conditions such as chronic obstructive pulmonary disease or pneumonia, not heart failure exacerbation. - C: Productive cough, dyspnea, weight loss, anorexia, and tuberculosis suggest a different diagnosis related to a respiratory infection like tuberculosis rather than heart failure exacerbation. - D: Fever, dry nonproductive cough, and diminished breath sounds are more suggestive of a respiratory infection like pneumonia,
Question 2 of 5
When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?
Correct Answer: C
Rationale: The correct answer is C because at birth, the opening in the atrial septum known as the foramen ovale allows blood to bypass the lungs and flow from the right atrium to the left atrium. This is essential as the lungs are not functional until the baby takes its first breath. The closure of the foramen ovale typically occurs within minutes to hours after birth as the pressure changes in the heart and lungs. Choice A is incorrect because the right ventricle is typically larger and weighs more than the left ventricle in a newborn due to the lower pressure needed to pump blood to the lungs. Choice B is incorrect as the circulation of a newborn is different from that of an adult, with shunts and openings that close or change soon after birth. Choice D is incorrect as the foramen ovale closes gradually over time after birth, not just minutes before, and the ductus arteriosus closes within a few days after birth, not immediately.
Question 3 of 5
The nurse is teaching a patient about the use of the diaphragm of a stethoscope. It is best used to detect:
Correct Answer: B
Rationale: The diaphragm of a stethoscope is best used to detect high-pitched breath sounds due to its ability to pick up higher frequency sounds. It is designed to transmit sound directly to the ear without amplifying it. High-pitched breath sounds such as wheezes or crackles are best heard using the diaphragm as it is more sensitive to these frequencies. Low-pitched heart murmurs (choice A) are better detected using the bell of the stethoscope as it is designed to pick up lower frequency sounds. Vascular bruits (choice C) are best heard with the bell as well, as they are low-frequency sounds. Extra heart sounds (choice D) may also be better detected using the bell due to their lower pitch. In summary, the diaphragm of a stethoscope is best suited for detecting high-pitched breath sounds, making choice B the correct answer in this scenario.
Question 4 of 5
Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely?
Correct Answer: B
Rationale: The correct answer is B: Herpes simplex. Frank's presentation of burning erosions on the penis and inguinal adenopathy is classic for genital herpes. Primary syphilis (A) typically presents with a painless chancre at the site of infection. Chancroid (C) presents with painful genital ulcers and inguinal lymphadenopathy. Gonorrhea (D) usually manifests with urethritis and discharge, not erosions on the penis. In this case, the key features of burning erosions and inguinal adenopathy point towards herpes simplex as the most likely diagnosis.
Question 5 of 5
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
Correct Answer: C
Rationale: The correct answer is C: To evaluate the adequacy of collateral circulation before cannulating the radial artery. The modified Allen test is performed to assess the patency of the ulnar artery and the adequacy of collateral circulation before cannulating the radial artery for procedures like arterial blood gas sampling or arterial line insertion. By compressing both the ulnar and radial arteries and releasing pressure on the ulnar artery, the nurse can observe how quickly the hand regains its color, indicating efficient collateral circulation. Choices A, B, and D are incorrect as they do not align with the purpose of the modified Allen test, which specifically focuses on evaluating collateral circulation in the hand.