ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have?
Correct Answer: A
Rationale: The correct answer is A: Acute orchitis. Orchitis is inflammation of the testicle, commonly caused by a viral infection (e.g., mumps) or a bacterial infection. In this case, the teenager presents with a swollen, tender left testicle, redness, and fever. The history of recent upper respiratory symptoms suggests a viral cause. Epididymitis (choice B) typically presents with pain in the scrotum and inflammation of the epididymis. Torsion of the spermatic cord (choice C) is a surgical emergency with sudden onset severe pain, absent cremasteric reflex, and high-riding testicle. Prostatitis (choice D) presents with symptoms like dysuria, pelvic pain, and fever, but the prostate exam here is unremarkable. Therefore, based on the clinical presentation and examination findings, the most likely diagnosis is acute orchitis.
Question 2 of 5
The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?
Correct Answer: C
Rationale: The correct answer is C: Palpable firm, small, shotty, mobile, and nontender lymph nodes. In a healthy 5-year-old with recent immunizations and no current illness, this finding is normal. Step 1: Palpable lymph nodes are expected in children due to their active immune system. Step 2: Small size, shotty consistency, and mobility indicate a benign and reactive nature. Step 3: Non-tender nodes suggest they are not inflamed or infected. Choices A, B, and D describe abnormal lymph node characteristics that could indicate infection or malignancy, which are not expected in this scenario.
Question 3 of 5
A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?
Correct Answer: B
Rationale: The correct answer is B: Small amplitude, weak. In congestive heart failure, the heart's ability to pump effectively is compromised, leading to reduced cardiac output. As a result, the pulse would be small in amplitude and weak. This is due to the heart's inability to generate enough force to produce a strong pulse. Choices A, C, and D are incorrect because in congestive heart failure, the pulse is not large amplitude, forceful, normal, or bigeminal. It is important to recognize the specific characteristics of the pulse in different medical conditions to make accurate assessments.
Question 4 of 5
You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Tachypnea (rapid breathing). This is a cue related to the patient's pain because pain can lead to increased respiratory rate as a physiological response. The body's natural reaction to pain is to increase breathing to provide more oxygen to tissues. Therefore, tachypnea is a relevant cue to assess pain levels. A: Normal skin turgor is not directly related to pain assessment. Skin turgor is typically assessed to evaluate hydration status. B: Normal S1, S2 heart sounds are not directly related to pain assessment. Heart sounds are assessed to evaluate cardiac function. C: Glowing skin is not a typical cue related to pain assessment. Glowing skin may be associated with overall health and well-being but is not directly related to pain.
Question 5 of 5
Mark each of the following statements as therapeutic or nontherapeutic. c. "Dr. Daniels knows what he is talking about. Just follow his recommendations."
Correct Answer: B
Rationale: The correct answer is B: Nontherapeutic. This statement is nontherapeutic because it implies a lack of autonomy and empowerment for the individual seeking help. It suggests blindly following advice without considering personal preferences or values. This can hinder the therapeutic process by diminishing the client's ability to actively participate in decision-making and problem-solving. Therapeutic communication focuses on collaboration, empowerment, and respect for the client's autonomy. Choices A, C, and D are left blank as they do not provide a suitable rationale for the given question.