ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse is performing a head-to-toe assessment. Which sequence of assessment techniques is correct for the abdominal region?
Correct Answer: C
Rationale: The correct sequence for assessing the abdominal region is inspection, auscultation, percussion, palpation (Choice C). Inspection allows visual assessment for any abnormalities. Auscultation should be done before palpation to prevent altering bowel sounds. Percussion helps assess for organ size and density. Palpation is done last to assess for tenderness, masses, and organ shape. Explanation for why the other choices are incorrect: A: Incorrect because palpation should be done after auscultation. B: Incorrect because auscultation should be done before palpation. D: Incorrect because palpation should be the last step in the sequence.
Question 2 of 5
The nurse is palpating lymph nodes during an assessment. Which characteristic of lymph nodes is concerning?
Correct Answer: D
Rationale: The correct answer is D: Hard and fixed. This characteristic is concerning as it may indicate malignancy or infection. Normal lymph nodes should be soft, mobile, and non-tender. Hard and fixed lymph nodes can be a sign of abnormal growth or metastasis. It is important to monitor such nodes closely and further investigate any concerning findings to rule out serious conditions. Choices A, B, and C describe normal characteristics of lymph nodes and are not typically concerning during assessment.
Question 3 of 5
The nurse is auscultating the lungs and hears a high-pitched, musical sound on expiration. What does this sound indicate?
Correct Answer: A
Rationale: The correct answer is A: Wheezing. Wheezing is a high-pitched, musical sound on expiration caused by narrowing of airways. This indicates obstruction in the lower respiratory tract, commonly seen in conditions like asthma or COPD. Crackles (B) are discontinuous, crackling sounds heard on inspiration and indicate fluid in the alveoli. Pleural friction rub (C) is a grating, rubbing sound heard during inspiration and expiration, suggesting inflammation of the pleura. Stridor (D) is a high-pitched, harsh sound heard on inspiration, indicating upper airway obstruction.
Question 4 of 5
Which finding during an abdominal assessment suggests the presence of ascites?
Correct Answer: B
Rationale: The correct answer is B: Shifting dullness on percussion. Ascites is the accumulation of fluid in the peritoneal cavity. When the patient is in a supine position, the fluid settles by gravity and causes dullness upon percussion in the dependent areas. Shifting dullness occurs when the patient is turned to the side, causing the fluid to shift and the dullness to move. This finding is specific to ascites. A: Hyperresonance on percussion is associated with bowel gas and is typically heard in cases of bowel obstruction. C: Borborygmi on auscultation refers to hyperactive bowel sounds and is not specific to ascites. D: Rebound tenderness on palpation indicates peritoneal irritation, often seen in cases of peritonitis, not ascites. In summary, shifting dullness on percussion is the key finding in assessing ascites due to the movement of fluid in the peritoneal cavity.
Question 5 of 5
During a neurological assessment, the nurse observes that the patient has difficulty pronating and supinating the hands rapidly. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A cerebellar dysfunction. This finding indicates cerebellar dysfunction because the cerebellum is responsible for coordinating rapid, smooth movements such as pronation and supination. A dysfunction in the cerebellum can result in impaired coordination and control of these movements. Incorrect choices: B: A cranial nerve deficit - Cranial nerves do not directly control pronation and supination. C: Impaired proprioception - Proprioception is the sense of body position and movement, not directly related to pronation and supination. D: Weakness in the upper extremities - Pronation and supination are more about coordination than strength.