ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
Which finding during a lung assessment indicates the presence of fluid in the alveoli?
Correct Answer: C
Rationale: The correct answer is C: Crackles on auscultation. Crackles are discontinuous, nonmusical sounds heard during inspiration that indicate the presence of fluid in the alveoli. This is because the fluid causes air to pass through the narrowed airways, creating the crackling sound. A: Hyperresonance on percussion is associated with conditions like emphysema, not fluid in the alveoli. B: Wheezing on auscultation is associated with airway narrowing and obstruction, not fluid in the alveoli. D: Dullness on percussion is indicative of consolidation or fluid in the pleural space, not specifically the alveoli.
Question 2 of 5
The nurse is assessing a patient's gait and observes shuffling and difficulty initiating movement. What condition is most likely associated with these findings?
Correct Answer: A
Rationale: The correct answer is A: Parkinson's disease. Shuffling gait and difficulty initiating movement are classic symptoms of Parkinson's disease due to the characteristic motor impairments and muscle rigidity associated with the condition. The basal ganglia dysfunction in Parkinson's leads to a lack of coordination in initiating and executing movements, resulting in the observed gait abnormalities. In contrast, stroke (B) typically presents with sudden onset focal neurological deficits, multiple sclerosis (C) involves demyelination of the central nervous system leading to various symptoms, and cerebral palsy (D) is a neurodevelopmental disorder present from childhood characterized by impaired movement and posture.
Question 3 of 5
During a cardiac assessment, the nurse notes a grade 3/6 systolic murmur at the left sternal border. What is the appropriate documentation for this finding?
Correct Answer: A
Rationale: Rationale for Correct Answer (A): 1. The term "systolic" indicates that the murmur occurs during systole. 2. The grade 3/6 signifies the loudness or intensity of the murmur. 3. "Heard best at the left sternal border" specifies the location where the murmur is most audible. 4. Therefore, documenting "Systolic murmur, grade 3/6, heard best at the left sternal border" accurately describes the finding. Incorrect Choices: B: Diastolic murmurs occur during diastole, not systole. C: A systolic click is a distinct sound different from a murmur. D: Diastolic clicks are also distinct sounds and do not indicate a murmur. Summary: Choice A is correct because it accurately describes the type, intensity, and location of the murmur. Choices B, C, and D are incorrect due to inaccuracies in the timing or nature of the sound
Question 4 of 5
What is the primary purpose of performing percussion during a physical examination?
Correct Answer: B
Rationale: The correct answer is B: To detect changes in the density of underlying structures. Percussion helps in assessing the density of organs or tissues by listening to the sounds produced. Denser structures produce dull sounds, while air-filled structures produce resonant sounds. This technique is commonly used to assess the lungs and abdominal organs. Choices A, C, and D are incorrect because percussion primarily focuses on evaluating the density, not texture, temperature, or pulses.
Question 5 of 5
The following information is recorded in the health history: 'I feel really tired.' Which category does it belong to?
Correct Answer: A
Rationale: The correct answer is A: Chief complaint. The chief complaint is the main reason for the patient seeking medical attention. In this case, "I feel really tired" is a subjective symptom that is bothering the patient and prompting them to seek help. It is the primary concern that needs to be addressed first. B: Present illness focuses on the current symptoms and how they developed, not just a general feeling of tiredness. C: Personal and social history pertains to the patient's background and lifestyle, not their immediate health concerns. D: Review of systems involves a systematic inquiry about specific symptoms or issues, not a general statement like feeling tired.