ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse is teaching a patient about the use of the diaphragm of a stethoscope. It is best used to detect:
Correct Answer: B
Rationale: The diaphragm of a stethoscope is best used to detect high-pitched breath sounds due to its ability to pick up higher frequency sounds. It is designed to transmit sound directly to the ear without amplifying it. High-pitched breath sounds such as wheezes or crackles are best heard using the diaphragm as it is more sensitive to these frequencies. Low-pitched heart murmurs (choice A) are better detected using the bell of the stethoscope as it is designed to pick up lower frequency sounds. Vascular bruits (choice C) are best heard with the bell as well, as they are low-frequency sounds. Extra heart sounds (choice D) may also be better detected using the bell due to their lower pitch. In summary, the diaphragm of a stethoscope is best suited for detecting high-pitched breath sounds, making choice B the correct answer in this scenario.
Question 2 of 5
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
Correct Answer: C
Rationale: The correct answer is C: To evaluate the adequacy of collateral circulation before cannulating the radial artery. The modified Allen test is performed to assess the patency of the ulnar artery and the adequacy of collateral circulation before cannulating the radial artery for procedures like arterial blood gas sampling or arterial line insertion. By compressing both the ulnar and radial arteries and releasing pressure on the ulnar artery, the nurse can observe how quickly the hand regains its color, indicating efficient collateral circulation. Choices A, B, and D are incorrect as they do not align with the purpose of the modified Allen test, which specifically focuses on evaluating collateral circulation in the hand.
Question 3 of 5
Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis?
Correct Answer: C
Rationale: The correct answer is C because cholecystitis typically presents with tenderness in the right upper quadrant (RUQ) due to inflammation of the gallbladder. The tenderness worsening with inspiration (Murphy's sign) indicates irritation of the peritoneum overlying the inflamed gallbladder. This is a classic finding in cholecystitis. Choices A, B, and D do not describe the characteristic RUQ tenderness with inspiration seen in cholecystitis. Choice A describes a normal abdomen, choice B suggests appendicitis, and choice D points more towards gastritis or pancreatitis.
Question 4 of 5
Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When you speak with him alone in the room, he states it "would be better if he were not here." What would you do next?
Correct Answer: D
Rationale: The correct answer is D: Assess his suicide risk. Given Adam's statement about it being better if he were not here and his recent behavioral changes, there are clear signs of potential suicidal ideation. It is crucial to prioritize assessing his immediate safety. This involves asking direct questions about suicide, assessing the presence of a suicide plan, means, and intent. This step is essential in ensuring Adam's safety and providing appropriate support and intervention if needed. Other choices are incorrect because: A: Offering vague reassurance about his promising future does not address the immediate concerns of potential suicide risk. B: Jumping to prescribing antidepressants without a thorough evaluation and risk assessment is premature and does not address the urgency of the situation. C: Speaking with his mother about getting him together with friends overlooks the seriousness of Adam's statement and the need for immediate intervention.
Question 5 of 5
S.Q. was just admitted because of cellulitis of her lower extremity due to a cat scratch. She was previously treated outpatient but missed multiple appointments and did not take her medication. As you complete the health history, she shares that she is sleeping on her sister's couch because she lost her job. She lives in an area of town considered a food desert and often eats whatever she can find from a local gas station or fast-food restaurant. She missed her last two follow-up visits for her leg due to inadequate transportation and could not afford to purchase the expensive medication. Which of the following statements best describes the impact of social determinants of health on S.Q.'s well-being?
Correct Answer: B
Rationale: The correct answer is B. Social determinants of health, such as lack of economic stability and limited access to nutritious food options, are negatively impacting S.Q.'s well-being. This choice is correct because it directly addresses the root causes of S.Q.'s health issues, including her living situation, financial struggles, and food insecurity. These factors significantly contribute to her inability to adhere to medical recommendations and access necessary healthcare. Incorrect answers: A: This choice incorrectly attributes S.Q.'s non-compliance to lack of motivation, ignoring the systemic barriers she faces. C: This choice implies that overcoming social determinants of health is solely dependent on individual effort, disregarding the structural factors that perpetuate disparities. D: This choice oversimplifies the situation by suggesting that S.Q. can improve her well-being solely through obtaining a new job, without acknowledging the complex interplay of social determinants impacting her health.