ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable. What disorder of the breast or axilla is she most likely to have?
Correct Answer: B
Rationale: The correct answer is B: Acanthosis nigricans. This condition presents as dark, velvet-like skin in areas such as the armpits and neck folds, commonly seen in individuals with insulin resistance or obesity. In this case, the patient's history of irregular periods, mild obesity, family history of type 2 diabetes, and skin changes are indicative of acanthosis nigricans. Peau d'orange is associated with breast cancer, which is not supported by the patient's presentation. Hidradenitis suppurativa presents with painful, recurrent abscesses in the axilla, which is not described in the patient. Choice D is not provided as an option.
Question 2 of 5
The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
Correct Answer: B
Rationale: Rationale: Option B is correct because gathering mental status information during the health history interview is a crucial and efficient way to assess a patient's mental state. Here's the rationale: 1. Mental status assessment during the health history interview allows for a comprehensive evaluation of the patient's current mental state. 2. It helps in identifying any immediate concerns or issues that may impact the patient's overall health and well-being. 3. Gathering mental status information early on can guide further assessment and interventions. 4. Conducting a separate mental status examination may be necessary in some cases, but integrating it into the health history interview streamlines the assessment process. In summary, option B is correct as it emphasizes the importance and efficiency of gathering mental status information during the health history interview, while the other choices provide inaccurate or irrelevant statements.
Question 3 of 5
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
Correct Answer: B
Rationale: The correct answer is B because the woman's verbal statement ("excited about the pregnancy") does not align with her nonverbal behaviors (looking nervously at her hands, sighing loudly). This inconsistency between verbal and nonverbal communication is a key indicator of potential underlying concerns or emotions that the woman may not be openly expressing. Option A can be ruled out because there is no direct indication of nervousness about labor. Option C is incorrect as there is no mention of the husband's feelings in the scenario. Option D is not supported by the information provided; the woman did not express fear of the nurse's response but rather exhibits nonverbal cues that may indicate hidden concerns or anxieties. Thus, option B is the most accurate choice based on the observed mismatch between verbal and nonverbal behaviors.
Question 4 of 5
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to 'warm up' and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Correct Answer: B
Rationale: The correct answer is B. Stopping down to the toddler's level and asking her about the toy she is holding is the best approach because it shows respect for the toddler's interests and allows for engagement on her terms, fostering a sense of trust and comfort. This approach acknowledges the toddler's autonomy and helps build a positive relationship. Option A is incorrect because tickling the toddler may not be appropriate and could potentially lead to discomfort or fear. Option C is incorrect as continuing to ignore the toddler may cause her to feel neglected and hinder the establishment of rapport. Option D is incorrect because it is important for the mother to be present to provide comfort and support during the examination.
Question 5 of 5
The nurse notes a drumlike percussion sound over the abdomen. This indicates:
Correct Answer: B
Rationale: The drumlike percussion sound over the abdomen suggests air-filled areas. This occurs because air in the stomach or intestines resonates when tapped, creating a hollow sound. This finding is consistent with conditions like gastric distention or bowel obstruction. Constipation (A) would not typically produce a drumlike sound. The presence of a tumor (C) or dense organs (D) would not lead to this specific percussion finding.