ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
The nurse recognizes that the concept of prevention in describing health is essential because:
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer): The nurse recognizes that prevention places emphasis on the link between health and personal behavior because an individual's actions and choices greatly influence their health outcomes. By focusing on prevention, individuals can proactively engage in healthy behaviors to reduce their risk of developing diseases or health complications. This approach empowers individuals to take control of their health and well-being, promoting long-term health benefits and reducing the burden on healthcare systems. Summary of Other Choices: A: Incorrect - Disease prevention involves more than just treating the external environment; it also includes individual behaviors and lifestyle choices. B: Incorrect - While some deaths may be unavoidable, prevention strategies can significantly reduce the incidence of many diseases and health conditions. D: Incorrect - Prevention is not solely reliant on treatment provided by primary health care practitioners; it involves a combination of individual behaviors, public health initiatives, and healthcare interventions.
Question 2 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 3 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 4 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.
Question 5 of 5
Which of the following is the most appropriate action when the nurse encounters an area of tenderness during abdominal palpation?
Correct Answer: B
Rationale: The most appropriate action when encountering tenderness during abdominal palpation is to palpate the tender area last (Choice B) to minimize discomfort for the patient. This approach allows the nurse to assess the less sensitive areas first, providing a baseline for comparison and ensuring a more thorough examination. Palpating the tender area last also helps to build trust with the patient by demonstrating sensitivity to their comfort and reducing anxiety. Skipping palpation (Choice A) may result in missing important findings, applying firm pressure (Choice C) could potentially cause unnecessary pain, and palpating the area first (Choice D) may lead to increased discomfort for the patient. Thus, Choice B is the most appropriate and patient-centered approach in this situation.