ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
During an examination, the nurse notices that a female patient has a round "moon" face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition?
Correct Answer: C
Rationale: The correct answer is C: Cushing syndrome. This condition is characterized by the symptoms described - "moon" face, central trunk obesity, cervical hump, fragile skin with bruises - due to excessive cortisol production. Marfan syndrome (A) is a genetic disorder affecting connective tissue, leading to tall stature and long limbs. Gigantism (B) is caused by excess growth hormone before puberty, resulting in abnormal growth. Acromegaly (D) is similar to gigantism but occurs after growth plates have closed, causing enlargement of bones and tissues. The symptoms described in the question are indicative of Cushing syndrome, thus making it the correct answer.
Question 2 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 3 of 5
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?
Correct Answer: B
Rationale: The correct answer is B because bloody or clear watery drainage can indicate a basal skull fracture, which is a serious complication of head injuries. Assessing for this type of drainage is crucial as it may signify a potentially life-threatening condition that requires immediate medical attention. A: Incorrect. Purulent drainage resulting from a ruptured eardrum is concerning but not as immediately life-threatening as a basal skull fracture. C: Incorrect. Increased cerumen occluding the auditory canal is not as urgent as identifying a basal skull fracture. D: Incorrect. While foreign bodies in the ear canal are important to assess, they are not as critical as identifying a basal skull fracture.
Question 4 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 5 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.