ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's:
Correct Answer: D
Rationale: The correct answer is D: Abdomen. The nurse should test skin mobility and turgor over the infant's abdomen because it is a reliable indicator of dehydration in infants. Dehydration can lead to decreased skin turgor, meaning that the skin will not bounce back quickly when pinched. The abdomen provides a larger surface area for assessment compared to the other options, making it easier to evaluate skin mobility and turgor accurately. Testing on the sternum, forehead, or forearms may not provide a clear assessment of dehydration in infants. Therefore, choosing the abdomen for skin mobility and turgor assessment is the most appropriate and reliable option in this scenario.
Question 2 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 3 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 4 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.
Question 5 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,