ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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 2 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 3 of 5
During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): 1. BSEs may detect lumps that appear between mammograms, ensuring early detection. 2. Early detection increases the chances of successful treatment and survival. 3. BSEs empower individuals to be proactive in their own health. Summary of Incorrect Choices: B. BSEs are recommended starting at age 20, not 50. C. Mammography and BSE serve different purposes; they are not interchangeable. D. Physician examinations are important but should not replace BSEs for early detection.
Question 4 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 5 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.