ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
Which of the following is a contraindication for the use of contrast baths?
Correct Answer: D
Rationale: The correct answer is D: Buerger's disease. Contrast baths involve alternating hot and cold water immersion, which can worsen symptoms in Buerger's disease due to impaired blood flow and potential for exacerbating vasospasm. Rheumatoid arthritis (A), complex regional pain syndrome (B), and muscular strain (C) are not absolute contraindications for contrast baths as they can benefit from the modality when used appropriately.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse is assessing a patient with suspected pneumonia. Which finding is most consistent with this condition?
Correct Answer: C
Rationale: The correct answer is C: Crackles in the affected lung. In pneumonia, the alveoli in the affected lung become filled with inflammatory exudate, leading to crackles on auscultation. This is due to the popping open of collapsed airways during inspiration. Hyperresonance (A) is more indicative of emphysema. Diminished breath sounds bilaterally (B) are often seen in conditions like asthma or chronic obstructive pulmonary disease. Symmetrical chest expansion (D) is normal and not specific to pneumonia. Therefore, in the context of suspected pneumonia, crackles in the affected lung are the most consistent finding.