ATI RN
health assessment exam 1 test bank Questions
Question 1 of 5
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
Question 2 of 5
Which technique should be used to assess a murmur in a patient's heart?
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location. A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs. C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs. D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
Question 3 of 5
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
Question 4 of 5
The interview portion of data collection obtains:
Correct Answer: D
Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.
Question 5 of 5
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over her other clothes. Her hair is dyed pink with black streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup. The nurse concludes that:
Correct Answer: D
Rationale: The correct answer is D because more information should be gathered to assess the situation appropriately. The woman's appearance may suggest alternative lifestyles or personal expression rather than mental health issues. It is essential to avoid assumptions based solely on appearance and gather a comprehensive history to understand her choices. Options A and B are dismissive and judgmental, failing to consider the complexity of human behavior. Option C is incorrect as the presented information does not provide enough evidence to diagnose manic syndrome. In summary, option D is the most logical and ethical approach to understanding the woman's situation without making unfounded assumptions.