ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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 2 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.
Question 3 of 5
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
Correct Answer: D
Rationale: The correct answer is D: Increased density of lung tissue. A dull percussion note over a lung lobe indicates increased density of the underlying tissue, which can be due to conditions like pneumonia, atelectasis, or pulmonary fibrosis. Shallow breathing (A) would not directly cause a dull percussion note. Normal lung tissue (B) would produce a resonant percussion note. Decreased adipose tissue (C) does not influence the percussion note over the lung. Therefore, the increased density of lung tissue (D) is the most likely cause for a dull percussion note.
Question 4 of 5
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
Correct Answer: A
Rationale: The correct answer is A. In a severe exacerbation of heart failure, the patient is likely to exhibit symptoms such as shortness of breath, orthopnea (difficulty breathing lying flat), paroxysmal nocturnal dyspnea (sudden onset of difficulty breathing at night), and ankle edema (swelling). These symptoms are classic signs of heart failure exacerbation due to fluid overload and poor cardiac function. Explanation for why the other choices are incorrect: - B: Rasping cough, thick mucoid sputum, wheezing, and bronchitis are more indicative of respiratory conditions such as chronic obstructive pulmonary disease or pneumonia, not heart failure exacerbation. - C: Productive cough, dyspnea, weight loss, anorexia, and tuberculosis suggest a different diagnosis related to a respiratory infection like tuberculosis rather than heart failure exacerbation. - D: Fever, dry nonproductive cough, and diminished breath sounds are more suggestive of a respiratory infection like pneumonia,
Question 5 of 5
During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): 1. BSEs may detect lumps that appear between mammograms, ensuring early detection. 2. Early detection increases the chances of successful treatment and survival. 3. BSEs empower individuals to be proactive in their own health. Summary of Incorrect Choices: B. BSEs are recommended starting at age 20, not 50. C. Mammography and BSE serve different purposes; they are not interchangeable. D. Physician examinations are important but should not replace BSEs for early detection.