ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 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 2 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 3 of 5
The nurse is assessing a patient's abdomen and hears high-pitched, tinkling bowel sounds. What do these sounds indicate?
Correct Answer: B
Rationale: The high-pitched, tinkling bowel sounds indicate a bowel obstruction. This is because the obstruction causes turbulent flow of air and fluid through the narrowed area, resulting in the tinkling sound. Normal bowel function (A) would have regular, soft, and low-pitched bowel sounds. Absent peristalsis (C) would result in no bowel sounds. Decreased bowel activity (D) would lead to hypoactive or decreased bowel sounds, not high-pitched tinkling sounds.
Question 4 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 5 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