ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct: 1. Checking the patient's comfort is crucial for accurate assessment. 2. Room temperature affects patient comfort and bowel motility. 3. Offering blankets helps maintain patient warmth during the examination. 4. Cold can lead to vasoconstriction affecting bowel sounds. 5. Ensuring patient comfort enhances trust and communication. Summary: A: Warming the stethoscope is unnecessary for assessing bowel sounds. B: Leaving the gown on may not address the patient's comfort needs. C: The bell side of the stethoscope position is not relevant to assessing bowel sounds.
Question 2 of 5
The nurse is assessing a patient with suspected pneumonia. Which finding is most consistent with this condition?
Correct Answer: C
Rationale: The correct answer is C: Crackles in the affected lung. In pneumonia, the alveoli in the affected lung become filled with inflammatory exudate, leading to crackles on auscultation. This is due to the popping open of collapsed airways during inspiration. Hyperresonance (A) is more indicative of emphysema. Diminished breath sounds bilaterally (B) are often seen in conditions like asthma or chronic obstructive pulmonary disease. Symmetrical chest expansion (D) is normal and not specific to pneumonia. Therefore, in the context of suspected pneumonia, crackles in the affected lung are the most consistent finding.
Question 3 of 5
Which finding during a lung assessment indicates the presence of fluid in the alveoli?
Correct Answer: C
Rationale: The correct answer is C: Crackles on auscultation. Crackles are discontinuous, nonmusical sounds heard during inspiration that indicate the presence of fluid in the alveoli. This is because the fluid causes air to pass through the narrowed airways, creating the crackling sound. A: Hyperresonance on percussion is associated with conditions like emphysema, not fluid in the alveoli. B: Wheezing on auscultation is associated with airway narrowing and obstruction, not fluid in the alveoli. D: Dullness on percussion is indicative of consolidation or fluid in the pleural space, not specifically the alveoli.
Question 4 of 5
The nurse is assessing a patient's abdomen and hears high-pitched, tinkling bowel sounds. What do these sounds indicate?
Correct Answer: B
Rationale: The high-pitched, tinkling bowel sounds indicate a bowel obstruction. This is because the obstruction causes turbulent flow of air and fluid through the narrowed area, resulting in the tinkling sound. Normal bowel function (A) would have regular, soft, and low-pitched bowel sounds. Absent peristalsis (C) would result in no bowel sounds. Decreased bowel activity (D) would lead to hypoactive or decreased bowel sounds, not high-pitched tinkling sounds.
Question 5 of 5
The nurse is assessing a patient's gait and observes shuffling and difficulty initiating movement. What condition is most likely associated with these findings?
Correct Answer: A
Rationale: The correct answer is A: Parkinson's disease. Shuffling gait and difficulty initiating movement are classic symptoms of Parkinson's disease due to the characteristic motor impairments and muscle rigidity associated with the condition. The basal ganglia dysfunction in Parkinson's leads to a lack of coordination in initiating and executing movements, resulting in the observed gait abnormalities. In contrast, stroke (B) typically presents with sudden onset focal neurological deficits, multiple sclerosis (C) involves demyelination of the central nervous system leading to various symptoms, and cerebral palsy (D) is a neurodevelopmental disorder present from childhood characterized by impaired movement and posture.