ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent?
Correct Answer: D
Rationale: The correct answer is D, an enlarged bladder. Given the patient's age and presentation of a smooth lower abdominal mass with dullness to percussion above the symphysis pubis, it is likely due to an enlarged bladder. This is indicative of urinary retention, common in elderly individuals. Other choices are less likely: A sigmoid mass would present differently, a tumor in the abdominal wall would not cause dullness to percussion, and a hernia would typically be reducible and not cause dullness.
Question 2 of 5
Which of the following is the most appropriate action when the nurse encounters an area of tenderness during abdominal palpation?
Correct Answer: B
Rationale: The most appropriate action when encountering tenderness during abdominal palpation is to palpate the tender area last (Choice B) to minimize discomfort for the patient. This approach allows the nurse to assess the less sensitive areas first, providing a baseline for comparison and ensuring a more thorough examination. Palpating the tender area last also helps to build trust with the patient by demonstrating sensitivity to their comfort and reducing anxiety. Skipping palpation (Choice A) may result in missing important findings, applying firm pressure (Choice C) could potentially cause unnecessary pain, and palpating the area first (Choice D) may lead to increased discomfort for the patient. Thus, Choice B is the most appropriate and patient-centered approach in this situation.
Question 3 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 4 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 5 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.