ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse is performing an abdominal examination and notes that the patient has tympany over the entire abdomen. What is the most likely cause of this finding?
Correct Answer: C
Rationale: The correct answer is C: Gas-filled intestines. Tympany over the entire abdomen indicates the presence of gas, which produces a resonant, drum-like sound upon percussion. This finding is characteristic of gas-filled intestines. Abdominal obstruction (A) would present with localized tympany and possibly a tympanic or dull sound in the affected area. Ascites (B) would result in dullness upon percussion due to fluid accumulation in the abdomen. Liver enlargement (D) would also lead to dullness upon percussion over the liver area, rather than tympany over the entire abdomen.
Question 2 of 5
During a musculoskeletal assessment, the nurse notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. In rheumatoid arthritis, patients typically present with tender, swollen joints and decreased range of motion due to joint inflammation and synovial thickening. This autoimmune condition affects multiple joints symmetrically. Osteoarthritis (A) is characterized by joint pain and stiffness, but not usually significant swelling or systemic symptoms like in rheumatoid arthritis. Gout (C) is characterized by sudden, severe pain, redness, and swelling, typically affecting one joint, often the big toe. Bursitis (D) is inflammation of the bursae sacs, causing localized pain and swelling, but not typically associated with significant joint stiffness or systemic symptoms as in rheumatoid arthritis.
Question 3 of 5
Core body temperature is ___ surface body temperature.
Correct Answer: B
Rationale: Higher than, is correct because core body temperature (e.g., rectal, tympanic) is typically 0.5°F-1°F higher than surface temperature (e.g., oral, axillary) due to proximity to internal organs and less environmental influence. Core sites reflect true metabolic heat, averaging 98.6°F-100.4°F, while surface sites like skin average 97°F-99°F. Less than, reverses this fact. Equal to, ignores the gradient. None of the above, dismisses the clear difference. This distinction is vital in nursinge.g., rectal readings are higher and more stable than axillary, guiding fever assessment. Physiological principles and clinical tools (e.g., thermometers) confirm B as the correct answer.
Question 4 of 5
A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient?
Correct Answer: B
Rationale: IV fluids in the right arm interfere with accurate blood pressure measurement due to altered circulation and pressure. Taking it in the left arm avoids this, ensuring a reliable reading. Using the right arm risks inaccuracy. A small cuff doesnt address the IV issue and may overestimate pressure. Reporting inability is unnecessary when the left arm is viable. Choice B is correct, reflecting standard practice to use the unaffected limb.
Question 5 of 5
The patient has a temperature of 105.2°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction , transferring heat from the skin to the cooler objects through direct contact. Radiation involves heat loss to the environment without contact, not the primary method here. Convection requires air movement (e.g., fans), not used. Evaporation occurs with moisture vaporizing, a minor effect with tepid water but not dominant. Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.