ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were 'messing around' and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is the most likely in her circumstance?
Correct Answer: A
Rationale: The most likely cause of nipple discharge in this 19-year-old female is a benign breast abnormality. This is supported by her age, absence of skin changes, negative pregnancy test, and lack of other significant findings on examination. The clear discharge that she experiences specifically upon squeezing the nipple is consistent with a benign etiology such as intraductal papilloma or duct ectasia. Breast cancer is less likely due to her young age and absence of risk factors. Nonpuerperal galactorrhea typically presents with milky discharge and is usually associated with hormonal imbalances, which are not evident in this case. Other systemic causes like thyroid disorders or medications are not suggested based on the given information. Therefore, based on her clinical presentation and examination findings, a benign breast abnormality is the most likely cause of her nipple discharge.
Question 2 of 5
When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
Correct Answer: D
Rationale: The correct answer is D: Sensory-perceptive abilities. Assessing sensory-perceptive abilities is crucial in understanding an aging adult's mental status as it can impact their ability to perceive and interpret information accurately. Impairments in sensory perception can lead to misinterpretation of situations, affecting their mental status assessment. Additionally, sensory deficits can mimic cognitive impairment, making it essential to rule out sensory issues first. Phobias (A), general intelligence (B), and irrational thinking patterns (C) are important aspects to consider but are secondary to sensory-perceptive abilities when assessing an aging adult's mental status.
Question 3 of 5
During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
Correct Answer: A
Rationale: The correct answer is A because a hallucination is a false sensory perception that does not correspond to reality. In this scenario, the man hearing his dead wife talking is an example of an auditory hallucination. This is a perception without any external stimuli. Choice B is incorrect because hearing the doorbell ring is a normal auditory perception, even if no one is actually there. Choice C is incorrect as seeing a man standing in the closet is an example of an illusion, not a hallucination, as the child's perception changes when the lights are turned on. Choice D is incorrect because mistaking a dog for a blanket is a misinterpretation of a real object, not a hallucination.
Question 4 of 5
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
Correct Answer: D
Rationale: The correct answer is D: Uncomfortable talking about his son's treatment. The sudden change in posture to a closed position (crossed arms and legs) signifies defensiveness or discomfort, possibly indicating emotional distress or difficulty discussing the topic. This nonverbal cue suggests a shift from openness to a protective stance, reflecting a potential reluctance or unease with the conversation. Choices A and B are incorrect as the change in posture was not simply for comfort or adjustment. Choice C is incorrect as there is no direct indication of tiredness or need for a break.
Question 5 of 5
During a physical examination, which action is most important for preventing infection?
Correct Answer: B
Rationale: The correct answer is B: Washing hands before and after patient contact. This is crucial for preventing infection as it reduces the spread of pathogens. Washing hands removes dirt and microbes that may be present on the hands, preventing their transfer to the patient or from the patient to the healthcare provider. Wearing gloves (choice A) is important but should not replace proper handwashing. Disinfecting equipment (choice C) is essential but not as critical as hand hygiene. Avoiding contact with the patient's skin (choice D) is unrealistic and not practical in a physical examination.