ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
During an eye assessment, the nurse uses the Snellen chart to test the patient's visual acuity. Which result is considered normal?
Correct Answer: B
Rationale: The correct answer is B: 20/20. In the Snellen chart, the first number represents the distance at which the test is performed (usually 20 feet) and the second number represents the distance at which a person with normal vision can read the same line. A person with 20/20 vision can read at 20 feet what a person with normal vision can read at 20 feet. Therefore, a result of 20/20 indicates normal visual acuity. Choices A, C, and D all indicate vision impairment as they represent the ability to read at a distance closer than 20 feet compared to a person with normal vision.
Question 2 of 5
A 70-year-old man with a history of hypertension presents with shortness of breath and orthopnea. His physical examination reveals bilateral pedal edema, crackles at the lung bases, and jugular venous distention. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Congestive heart failure. This diagnosis is likely due to the patient's history of hypertension, presenting symptoms of shortness of breath, orthopnea, bilateral pedal edema, crackles at lung bases, and jugular venous distention. These findings are classic signs of congestive heart failure, indicating impaired heart function leading to fluid accumulation in the lungs and peripheral tissues. Chronic obstructive pulmonary disease (choice A) typically presents with a history of smoking, productive cough, and wheezing, not consistent with this patient's presentation. Pulmonary embolism (choice C) would present with sudden onset dyspnea and chest pain, not gradual symptoms as seen here. Renal failure (choice D) can cause fluid retention, but the combination of symptoms and signs in this patient points more towards congestive heart failure.
Question 3 of 5
A 70-year-old man presents with a complaint of severe, crushing chest pain that radiates to his left arm. He has a history of hypertension and diabetes mellitus. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Myocardial infarction. Given the patient's age, risk factors (hypertension, diabetes), and symptoms (severe chest pain radiating to left arm), myocardial infarction is the most likely diagnosis. In myocardial infarction, there is a blockage of blood flow to the heart muscle leading to tissue damage. Angina (choice A) is similar but is usually relieved by rest or medication. Aortic dissection (choice C) presents with sudden, severe chest or back pain. Pulmonary embolism (choice D) typically presents with sudden shortness of breath and chest pain worsened by breathing.
Question 4 of 5
The nurse is assessing a patient's peripheral pulses and notes that the pulse is weak and thready. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Hypovolemia. Weak and thready pulses are indicative of decreased blood volume, which is a characteristic of hypovolemia. When there is not enough blood circulating in the body, peripheral pulses may become weak and difficult to palpate. Other choices are incorrect because: B: Hypervolemia would typically present with bounding pulses due to excess fluid volume. C: Arterial occlusion would result in absent or diminished pulses, not weak and thready pulses. D: Peripheral edema would not directly affect the strength or quality of peripheral pulses.
Question 5 of 5
The nurse is performing an abdominal examination and notes that the patient has tympany over the entire abdomen. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Gas-filled intestines. Tympany over the entire abdomen indicates the presence of gas, which produces a resonant, drum-like sound upon percussion. This finding is characteristic of gas-filled intestines. Abdominal obstruction (A) would present with localized tympany and possibly a tympanic or dull sound in the affected area. Ascites (B) would result in dullness upon percussion due to fluid accumulation in the abdomen. Liver enlargement (D) would also lead to dullness upon percussion over the liver area, rather than tympany over the entire abdomen.