ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse is conducting a class on priority setting for new graduate nurses. Which is an example of a first-level priority problem?
Correct Answer: D
Rationale: The correct answer is D because a patient with shortness of breath and respiratory distress is experiencing a life-threatening emergency that requires immediate intervention to ensure airway patency and oxygenation. This falls under the first-level priority, which addresses issues that are crucial for the patient's survival. Postoperative pain (A) is important but not life-threatening. Diabetic teaching (B) can be addressed later as it is not an immediate threat. A small laceration (C) can be managed with basic wound care and is not as urgent as respiratory distress.
Question 2 of 5
Which of the following is a contraindication for the use of contrast baths?
Correct Answer: D
Rationale: The correct answer is D: Buerger's disease. Contrast baths involve alternating hot and cold water immersion, which can worsen symptoms in Buerger's disease due to impaired blood flow and potential for exacerbating vasospasm. Rheumatoid arthritis (A), complex regional pain syndrome (B), and muscular strain (C) are not absolute contraindications for contrast baths as they can benefit from the modality when used appropriately.
Question 3 of 5
A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential?
Correct Answer: D
Rationale: The correct answer is D: Hypertensive retinopathy. When examining a patient with red reflexes bilaterally, it indicates that light is reflecting off the retina, suggesting normal retinal function. Hypertensive retinopathy typically presents with signs such as flame-shaped hemorrhages, cotton-wool spots, and papilledema, which are not consistent with a normal red reflex. Retinoblastoma (A) would present as a white pupillary reflex, cataract (B) as opacity in the lens, and an artificial eye (C) would not have a red reflex at all. Therefore, by observing red reflexes bilaterally, you essentially exclude hypertensive retinopathy.
Question 4 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 5 of 5
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct: 1. Checking the patient's comfort is crucial for accurate assessment. 2. Room temperature affects patient comfort and bowel motility. 3. Offering blankets helps maintain patient warmth during the examination. 4. Cold can lead to vasoconstriction affecting bowel sounds. 5. Ensuring patient comfort enhances trust and communication. Summary: A: Warming the stethoscope is unnecessary for assessing bowel sounds. B: Leaving the gown on may not address the patient's comfort needs. C: The bell side of the stethoscope position is not relevant to assessing bowel sounds.