ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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.
Question 2 of 5
During a physical examination, which action is most important for preventing infection?
Correct Answer: B
Rationale: The correct answer is B: Washing hands before and after patient contact. This is crucial for preventing infection as it reduces the spread of pathogens. Washing hands removes dirt and microbes that may be present on the hands, preventing their transfer to the patient or from the patient to the healthcare provider. Wearing gloves (choice A) is important but should not replace proper handwashing. Disinfecting equipment (choice C) is essential but not as critical as hand hygiene. Avoiding contact with the patient's skin (choice D) is unrealistic and not practical in a physical examination.
Question 3 of 5
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
Correct Answer: C
Rationale: The correct technique for measuring chest circumference in infants is at the nipple line, as this is the standard anatomical landmark for consistency. Measuring at this point ensures accurate and reliable data for growth monitoring. Measuring the length of an infant with a tape measure (choice A) is correct for assessing height. Weighing the infant on an electronic standing scale (choice B) is appropriate for measuring weight. Measuring head circumference by wrapping the tape measure over the nose and cheekbones (choice D) is incorrect, as it can lead to inaccurate measurements.
Question 4 of 5
A student is late for his appointment and has rushed across campus to the health clinic. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because allowing the student 5 minutes to relax and rest before checking his vital signs is important for obtaining accurate readings. When someone rushes across campus, their heart rate and blood pressure are likely elevated, which can lead to inaccurate readings if taken immediately. Allowing the student to relax will help stabilize their vital signs and provide a more accurate baseline measurement. Choice B is incorrect because checking blood pressure in both arms expecting a difference due to recent exercise is not necessary in this scenario. Choice C is incorrect as immediate monitoring may not provide accurate readings due to the student's rushed state. Choice D is incorrect as checking blood pressure in the supine position is not necessary and may not accurately reflect the student's true vital signs in this situation.
Question 5 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.