ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy. Which abnormality of the penis does this patient most likely have?
Correct Answer: A
Rationale: The correct answer is A: Condylomata acuminata. The presence of moist papules on the penile shaft and corona, absence of pain with intercourse or urination, multiple sexual partners, lack of systemic symptoms, and absence of inguinal lymphadenopathy are all consistent with condylomata acuminata, which are caused by human papillomavirus (HPV) infection. Genital herpes (B) typically presents with painful vesicles, syphilitic chancre (C) presents as a painless ulcer with associated systemic symptoms, and penile carcinoma (D) usually presents with a single firm, non-tender lesion and may have associated risk factors like smoking or HPV infection, which are not present in this case.
Question 2 of 5
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
Correct Answer: A
Rationale: The correct answer is A: 1+/0-4+. This grading scale indicates mild pitting edema. The "1+" signifies slight indentation that disappears rapidly (mild), and "0-4+" indicates the depth of the indentation, with 1+ being the lowest on the scale. This specific documentation helps accurately communicate the severity of the edema. Summary of other choices: - B: 3+/0-4+: This indicates moderate to severe pitting edema, not appropriate for mild edema. - C: 4+/0-4+: This indicates severe pitting edema, not reflective of mild edema. - D: Brawny edema: Brawny edema is non-pitting and does not apply to the scenario described.
Question 3 of 5
You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning?
Correct Answer: B
Rationale: The correct answer is B because reassuring the patient that urinary symptoms are benign and not related to cancer is not a component of adaptive questioning. Adaptive questioning involves adjusting the questioning technique based on the patient's responses to gather more information effectively. Reassurance may prematurely close the conversation or influence the patient's responses. Directed questioning (A) is a component of adaptive questioning as it helps gather information systematically. Offering multiple choices (C) helps clarify the patient's symptoms. Asking the patient to explain further (D) is also a component of adaptive questioning as it seeks detailed information to better understand the patient's experience.
Question 4 of 5
A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this is at her hands and feet. She does not remember the child's lips turning blue. She is otherwise eating and growing well. What would you do now?
Correct Answer: A
Rationale: Step 1: "Turns blue" at hands and feet without lips involvement suggests acrocyanosis, a common benign condition in newborns. Step 2: Acrocyanosis is a result of immature circulation and is typically self-limiting. Step 3: The child is otherwise well-nourished and growing, indicating no acute distress. Step 4: Reassuring the mother about acrocyanosis being normal helps alleviate her concerns. Summary: B: Echocardiogram is unnecessary as the symptoms do not suggest structural heart disease. C: Hospitalization is excessive for a benign condition like acrocyanosis. D: Casting doubt on the mother's story is not appropriate without evidence otherwise.
Question 5 of 5
M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse?
Correct Answer: A
Rationale: The correct answer is A: "Tell me what prompted that question." This response shows empathy, encourages open communication, and allows M.J. to express her concerns. By asking for clarification, the nurse can assess M.J.'s understanding and emotional state, providing an opportunity to address her fears and offer support. This approach respects M.J.'s autonomy and allows her to share her feelings. Choice B: "I will ask your physician to discuss this matter with you." This response avoids addressing M.J.'s concerns directly and may not respect her preferences for communication. Choice C: "Let's take each day as it comes." This response does not directly address M.J.'s question and may come across as dismissive of her concerns. Choice D: "I think you should discuss that with your family." This response does not acknowledge M.J.'s feelings or provide direct support, potentially undermining the therapeutic relationship between the nurse and M.J.