ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A 24-year-old travel agent comes to your clinic, complaining of pain and swelling in her vulvar area. She states that 2 days earlier she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago and she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum, a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems?
Correct Answer: A
Rationale: The correct answer is A: Bartholin's gland infection. The patient's symptoms of pain, swelling, tenderness, and the presence of a red, tense swelling to the left of her introitus are classic signs of Bartholin's gland infection. The Bartholin's gland is located at the entrance to the vagina and can become infected, leading to the formation of a painful abscess. The patient's age, sexual activity, and use of contraception are all risk factors for developing this condition. The absence of systemic symptoms such as fever, along with the localized nature of the swelling, further support this diagnosis. The other choices are incorrect because: B: Vulvar carcinoma typically presents with different symptoms such as persistent itching, bleeding, or changes in the appearance of the skin. C: Secondary syphilis would present with systemic symptoms like rash, fever, and lymphadenopathy, which are absent in this case. D: Condylomata acuminata (genital warts) usually
Question 2 of 5
Which of the following percussion notes would you obtain over the gastric bubble?
Correct Answer: B
Rationale: The correct answer is B: Tympany. When percussing over the gastric bubble, you would expect to hear a tympanic sound due to the presence of gas in the stomach. Tympany is characterized by a drum-like, hollow sound. Resonance (A) is a normal lung sound, hyperresonance (C) is indicative of hyperinflation of the lungs, and flatness (D) is typically heard over solid organs or areas of consolidation in the lungs. Therefore, the presence of a gastric bubble would produce a tympanic note on percussion.
Question 3 of 5
Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Correct Answer: D
Rationale: The correct answer is D because the older adult man's statement about joining his wife in heaven and planning to use a gun indicates specific intent and means for suicide. This combination of intent and method poses the highest risk for an imminent suicide attempt. Choice A is incorrect because joking about death does not necessarily indicate a high risk for suicide. Choice B, while concerning, refers to a past suicide attempt and does not provide current information to suggest an imminent risk. Choice C, although expressing suicidal ideation, lacks a clear plan or intent.
Question 4 of 5
A woman is discussing the problems she is having with her 2-year-old son. She says, 'He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens.' The nurse's best verbal response would be:
Correct Answer: B
Rationale: The correct answer is B: "Fits? Tell me what you mean by this." This response shows active listening and seeks clarification, allowing the nurse to gather more information to better understand the situation and provide appropriate support. It demonstrates empathy and encourages the woman to express her concerns further. Choices A and C are less effective because they do not address the specific issue of the fits the child is having. Choice D is incorrect as it dismisses the woman's emotions and fails to address the underlying problem. Overall, choice B is the best response as it promotes effective communication and understanding between the nurse and the woman.
Question 5 of 5
Before auscultating the abdomen for bowel sounds, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because checking the room temperature and ensuring patient comfort is crucial before auscultating the abdomen to prevent any environmental factors from affecting the patient's comfort or bowel sounds. A, warming the stethoscope, is unnecessary and could potentially be uncomfortable for the patient. B, leaving the gown on, may interfere with the ability to properly listen to bowel sounds. C, ensuring the bell side of the stethoscope is on, is important but not the primary consideration before auscultating the abdomen.