health assessment exam 2 test bank

Questions 37

ATI RN

ATI RN Test Bank

health assessment exam 2 test bank Questions

Question 1 of 5

What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Question 2 of 5

What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Question 3 of 5

A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of worsening heart failure?

Correct Answer: D

Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.

Question 4 of 5

During an interview, a woman says, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?

Correct Answer: B

Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation. Rationale: 1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings. 2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support. 3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication. 4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress. Summary of other choices: A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively. C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears. D: Incorrect. While the response did minimize the patient

Question 5 of 5

A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

Correct Answer: D

Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.

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