ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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 2 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 3 of 5
The nurse is assessing a patient's gait and observes shuffling and difficulty initiating movement. What condition is most likely associated with these findings?
Correct Answer: A
Rationale: The correct answer is A: Parkinson's disease. Shuffling gait and difficulty initiating movement are classic symptoms of Parkinson's disease due to the characteristic motor impairments and muscle rigidity associated with the condition. The basal ganglia dysfunction in Parkinson's leads to a lack of coordination in initiating and executing movements, resulting in the observed gait abnormalities. In contrast, stroke (B) typically presents with sudden onset focal neurological deficits, multiple sclerosis (C) involves demyelination of the central nervous system leading to various symptoms, and cerebral palsy (D) is a neurodevelopmental disorder present from childhood characterized by impaired movement and posture.
Question 4 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 5 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.