ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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.
Question 2 of 5
During a cardiac assessment, the nurse notes a grade 3/6 systolic murmur at the left sternal border. What is the appropriate documentation for this finding?
Correct Answer: A
Rationale: Rationale for Correct Answer (A): 1. The term "systolic" indicates that the murmur occurs during systole. 2. The grade 3/6 signifies the loudness or intensity of the murmur. 3. "Heard best at the left sternal border" specifies the location where the murmur is most audible. 4. Therefore, documenting "Systolic murmur, grade 3/6, heard best at the left sternal border" accurately describes the finding. Incorrect Choices: B: Diastolic murmurs occur during diastole, not systole. C: A systolic click is a distinct sound different from a murmur. D: Diastolic clicks are also distinct sounds and do not indicate a murmur. Summary: Choice A is correct because it accurately describes the type, intensity, and location of the murmur. Choices B, C, and D are incorrect due to inaccuracies in the timing or nature of the sound
Question 3 of 5
What is the primary purpose of performing percussion during a physical examination?
Correct Answer: B
Rationale: The correct answer is B: To detect changes in the density of underlying structures. Percussion helps in assessing the density of organs or tissues by listening to the sounds produced. Denser structures produce dull sounds, while air-filled structures produce resonant sounds. This technique is commonly used to assess the lungs and abdominal organs. Choices A, C, and D are incorrect because percussion primarily focuses on evaluating the density, not texture, temperature, or pulses.
Question 4 of 5
The following information is recorded in the health history: 'I feel really tired.' Which category does it belong to?
Correct Answer: A
Rationale: The correct answer is A: Chief complaint. The chief complaint is the main reason for the patient seeking medical attention. In this case, "I feel really tired" is a subjective symptom that is bothering the patient and prompting them to seek help. It is the primary concern that needs to be addressed first. B: Present illness focuses on the current symptoms and how they developed, not just a general feeling of tiredness. C: Personal and social history pertains to the patient's background and lifestyle, not their immediate health concerns. D: Review of systems involves a systematic inquiry about specific symptoms or issues, not a general statement like feeling tired.
Question 5 of 5
Which of the following symptoms is relevant to the gastrointestinal system?
Correct Answer: C
Rationale: The correct answer is C: Nausea. Nausea is a symptom related to the gastrointestinal system as it often indicates issues such as stomach problems or digestive disturbances. It can be caused by various gastrointestinal conditions like gastritis, gastroenteritis, or peptic ulcers. Cough (A) and chest pain (B) are more likely related to respiratory or cardiac issues, respectively. Polyuria (D) is a symptom of excessive urination, pointing towards potential kidney or endocrine system problems, not the gastrointestinal system.