ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
Conducting a health assessment involves collecting, validating, and analyzing subjective data and objective data. Which of the following is an example of subjective data?
Correct Answer: A
Rationale: Pain is subjective data, per the answer key, as it's the patient's personal experience, reported verbally (e.g., intensity, location). Rash , perspiration , and fever are objectivevisible or measurable by the nurse. Subjective data drives patient-centered care, relying on the patient's perception, unlike objective signs assessed directly. Nurses use this distinction, per Taylor's fundamentals, to build a holistic health picture, ensuring symptoms like pain inform the nursing process effectively.
Question 2 of 5
A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were 'messing around' and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is the most likely in her circumstance?
Correct Answer: A
Rationale: The most likely cause of nipple discharge in this 19-year-old female is a benign breast abnormality. This is supported by her age, absence of skin changes, negative pregnancy test, and lack of other significant findings on examination. The clear discharge that she experiences specifically upon squeezing the nipple is consistent with a benign etiology such as intraductal papilloma or duct ectasia. Breast cancer is less likely due to her young age and absence of risk factors. Nonpuerperal galactorrhea typically presents with milky discharge and is usually associated with hormonal imbalances, which are not evident in this case. Other systemic causes like thyroid disorders or medications are not suggested based on the given information. Therefore, based on her clinical presentation and examination findings, a benign breast abnormality is the most likely cause of her nipple discharge.
Question 3 of 5
A 36-year-old teacher presents with sharp, knifelike pain on the left side of her chest for 2 days. Breathing and lying down make the pain worse, while sitting forward helps. A scratching noise is heard at the lower left sternal border, coincident with systole.
Correct Answer: B
Rationale: The correct answer is B: Pericarditis. The key findings in this scenario are sharp chest pain worsened by breathing and lying down but improved by sitting forward, which is characteristic of pericarditis. The scratching noise heard at the lower left sternal border during systole is known as a pericardial friction rub, a classic sign of pericarditis. Angina pectoris typically presents as chest discomfort or pressure that is relieved by rest, nitroglycerin, or both. Dissecting aortic aneurysm usually presents with severe, tearing chest pain that may radiate to the back. Pleural pain is typically sharp and worsened by coughing or deep breathing, not necessarily positional like in this case.
Question 4 of 5
When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
Correct Answer: D
Rationale: The correct answer is D: Sensory-perceptive abilities. Assessing sensory-perceptive abilities is crucial in understanding an aging adult's mental status as it can impact their ability to perceive and interpret information accurately. Impairments in sensory perception can lead to misinterpretation of situations, affecting their mental status assessment. Additionally, sensory deficits can mimic cognitive impairment, making it essential to rule out sensory issues first. Phobias (A), general intelligence (B), and irrational thinking patterns (C) are important aspects to consider but are secondary to sensory-perceptive abilities when assessing an aging adult's mental status.
Question 5 of 5
During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
Correct Answer: A
Rationale: The correct answer is A because a hallucination is a false sensory perception that does not correspond to reality. In this scenario, the man hearing his dead wife talking is an example of an auditory hallucination. This is a perception without any external stimuli. Choice B is incorrect because hearing the doorbell ring is a normal auditory perception, even if no one is actually there. Choice C is incorrect as seeing a man standing in the closet is an example of an illusion, not a hallucination, as the child's perception changes when the lights are turned on. Choice D is incorrect because mistaking a dog for a blanket is a misinterpretation of a real object, not a hallucination.