ATI RN
Physical Assessment NCLEX Practice Questions Questions
Question 1 of 5
Which of the following is true of jugular venous pressure (JVP) measurement?
Correct Answer: B
Rationale: Jugular venous pressure (JVP) is measured as the vertical height of the blood column in centimeters above the sternal angle (Angle of Louis). To measure the JVP accurately, the patient should be positioned at a 30-45 degree angle (not 45-degree angle as in choice A). The value obtained by measuring the JVP in centimeters is then added to 5 cm, which represents the distance from the sternal angle to the right atrium. Therefore, the formula for calculating JVP is the vertical height of the blood column in cm + 5 cm. A JVP below 9 cm (not 9 cm or choice C) is generally considered normal, while a JVP above that level is considered elevated. It is important to measure the JVP correctly and interpret the findings in the context of the patient's
Question 2 of 5
When should a woman conduct breast self-examination with respect to her menses?
Correct Answer: C
Rationale: It is recommended for women to conduct breast self-examination immediately prior to their menses. This is because the breasts are less likely to be tender, lumpy, or swollen during this time of the menstrual cycle, making it easier to detect any abnormalities such as lumps or changes in the breast tissue. Conducting breast self-examination around this time each month can help women become familiar with the normal look and feel of their breasts, making it easier to detect any changes that may indicate a potential issue.
Question 3 of 5
His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?
Correct Answer: A
Rationale: The presentation of decreased bowel sounds, rebound tenderness, and involuntary guarding in the right lower quadrant is highly suggestive of acute appendicitis. These signs indicate inflammation and potential perforation of the appendix, leading to the classic symptoms of appendicitis. The pain in this case is likely due to the inflammatory process involving the appendix. The absence of abnormal findings in the rectal, inguinal, prostate, penile, and testicular examinations further supports the diagnosis of acute appendicitis as the most likely cause of the patient's pain.
Question 4 of 5
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
Correct Answer: A
Rationale: A splenic rub is a friction rub heard on auscultation in the left upper quadrant of the abdomen, typically in patients with an enlarged spleen. The rough grating noise heard during examination is due to the rubbing together of the inflamed or irritated peritoneal surfaces surrounding the spleen. This is a classic finding in patients with splenomegaly and is often associated with left upper quadrant pain. Bowel noises (borborygmi) are typically heard in the abdomen and are softer, gurgling, or rumbling in nature. Vascular noises are related to blood flow and are typically not associated with such sounds in the abdomen.
Question 5 of 5
A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. You are concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate to order to initially evaluate for this condition?
Correct Answer: C
Rationale: The ankle-brachial index (ABI) is the appropriate test to initially evaluate for peripheral vascular disease in this case. ABI is a simple, non-invasive test that compares the blood pressure in the arms to the blood pressure in the legs. A lower ABI value indicates a higher likelihood of peripheral arterial disease (PAD). Given the patient's presentation of leg swelling and risk factors like smoking and hypertension, ABI can help determine the presence and severity of PAD, guiding further management and treatment decisions.