ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
A 34-year-old married daycare worker comes to your office, complaining of severe pelvic pain for the last 6 hours. She states that the pain was at first cramp-like but is now sharp. Nothing makes the pain better or worse. She has had no vaginal bleeding or discharge. She has had no pain with urination. She has had some nausea for the last few days but denies vomiting, constipation, or diarrhea. She states she feels so bad that when she stands up she has fainted. Her past medical history consists of two prior cesarean sections and an appendectomy. She is married and has two children. She denies any tobacco, alcohol, or drug use. Her parents are both healthy. On examination you find a pale young woman who is obviously in a great deal of pain. She is lying on her right side with her eyes closed. Her blood pressure is 90/60 and her pulse is 110. She is afebrile. She has bowel sounds and her abdomen is soft. The speculum examination reveals a bluish cervix but no blood or purulent discharge at the os. There is a mild amount of tenderness with palpation of the cervix. The uterus is nongravid but the right adnexal area is swollen and very tender. Urine analysis is normal and the urine pregnancy test is pending. What type of adnexal disorder is causing her pain?
Correct Answer: B
Rationale: The correct answer is B: Tubal pregnancy. The patient's presentation is concerning for an ectopic pregnancy, where the fertilized egg implants outside the uterus, typically in the fallopian tube. The sharp pelvic pain, history of fainting, and tender adnexal area are classic signs of a tubal pregnancy. The absence of vaginal bleeding or discharge makes other causes less likely. Ovarian cysts would typically present with more gradual onset and less severe pain. Pelvic inflammatory disease usually presents with vaginal discharge and fever, which are not present in this case. The patient's history of two prior cesarean sections and symptoms of nausea are also supportive of a tubal pregnancy. Immediate intervention is crucial to prevent rupture and life-threatening bleeding.
Question 2 of 5
Which of the following occurs in respiratory distress?
Correct Answer: B
Rationale: The correct answer is B because skin between the ribs moving inward with inspiration indicates increased work of breathing, a characteristic of respiratory distress. This is due to the increased effort needed to expand the chest cavity to inhale sufficient oxygen. Choices A, C, and D are incorrect because speaking in sentences of 10-20 words suggests adequate air exchange for speech, relaxed neck muscles are not indicative of distress, and leaning posteriorly is not a typical sign of respiratory distress.
Question 3 of 5
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.
Correct Answer: C
Rationale: The correct answer is C: Recall; after a 30-minute delay. In the Four Unrelated Words Test, the individual is asked to recall four unrelated words after a brief delay. A 30-minute delay is crucial as it tests the individual's ability to retain and retrieve information from their long-term memory. If the individual struggles with this task, it may indicate potential memory impairment or cognitive decline. Choices A and B are incorrect as the test focuses on recall, not invention, and the time frame is typically longer than 5 minutes or 30 seconds. Choice D is incorrect as a 60-minute delay is too long for this specific test.
Question 4 of 5
In using verbal responses to assist the patient's narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective. An example of a verbal response that focuses on the health care provider's perspective would be:
Correct Answer: D
Rationale: The correct answer is D: Confrontation. Confrontation is a verbal response that focuses on the health care provider's perspective by directly addressing discrepancies or inconsistencies in the patient's narrative. This technique helps challenge the patient's denial or resistance to change, promoting self-awareness and insight. In contrast, empathy (choice A) involves understanding and sharing the patient's feelings, reflection (choice B) involves restating or paraphrasing the patient's words, and facilitation (choice C) involves encouraging the patient to continue expressing their thoughts. These responses all focus on the patient's frame of reference, rather than challenging or addressing the provider's perspective.
Question 5 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. Bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child indicate normal resonance due to increased air content in the lungs. This finding is consistent with normal lung sounds in children of this age. Palpating for pain or tenderness (choice A) is not indicated as the percussion findings are normal. Asking the child to take shallow breaths (choice B) would not change the percussion findings. Immediate referral (choice C) is unnecessary as the percussion findings are within the normal range for a child of this age.