ATI RN
Assess Vital Signs Questions
Question 1 of 5
A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?
Correct Answer: B
Rationale: The correct answer is B: Lymphadenopathy of infectious origin. The patient's presentation of a painful, tender, movable lymph node in the left axilla, associated with a tense red area and a scabbed-over superficial laceration on the left hand, suggests an inflammatory response due to an infection. The history of recent cut from gardening increases the likelihood of an infectious etiology. Breast cancer (choice A) is less likely given the acuity of symptoms, lack of breast abnormalities on examination, and the presence of a clear inciting event. Hidradenitis suppurativa (choice C) typically presents with recurrent painful nodules in areas with apocrine sweat glands, not usually associated with enlarged and tender lymph nodes. Choice D is not provided.
Question 2 of 5
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action?
Correct Answer: A
Rationale: The correct answer is A: Perform a complete mental status examination. This is the best course of action as memory loss following a fall can be indicative of a serious condition such as a concussion or traumatic brain injury. A complete mental status examination will help assess various cognitive functions such as memory, orientation, attention, and reasoning abilities. This will provide a comprehensive evaluation of the husband's mental health and cognitive functioning, helping to identify any underlying issues that may require further intervention or treatment. Choice B is incorrect because a psychometrician typically focuses on administering and interpreting psychological tests, which may not address the immediate concerns related to memory loss after a fall. Choice C is not the best course of action as integrating the mental status examination into the history and physical examination may not provide a thorough assessment of the husband's cognitive abilities. Choice D is incorrect as memory loss after a physical shock should not be dismissed without a proper evaluation, as it could be a symptom of a more serious condition.
Question 3 of 5
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
Correct Answer: C
Rationale: The correct answer is C because the man whose wife has just been diagnosed with lung cancer is emotionally distressed, which can impact his ability to accurately interpret the message. This emotional state may lead to misinterpretations due to heightened stress and distraction. A: Well-adjusted adolescent - Unlikely to misinterpret as they are in a stable emotional state. B: Recovering alcoholic - Unlikely to misinterpret unless under the influence, which is not specified. D: Man with a hearing impairment - Unlikely to misinterpret with the presence of an interpreter for accurate communication.
Question 4 of 5
When performing a physical assessment, the first technique the nurse will always use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. When performing a physical assessment, inspection is always the first technique used as it provides an overall view of the patient's appearance and any obvious abnormalities. This includes observing skin color, posture, gait, facial expressions, and any visible signs of distress. Inspection helps the nurse gather initial information before proceeding to palpation, percussion, and auscultation. Palpation (A) involves using touch to assess areas such as texture, temperature, and tenderness. Percussion (C) is tapping on the body to produce sounds that indicate the location, size, and density of underlying structures. Auscultation (D) is listening to sounds produced by the body using a stethoscope. These techniques are important in a comprehensive physical assessment but come after inspection.
Question 5 of 5
The nurse is examining a preschool-aged child. What approach should the nurse use?
Correct Answer: B
Rationale: The correct answer is B because reassuring and providing feedback throughout the exam helps build trust and comfort with the child, making the exam less daunting. This approach fosters a positive therapeutic relationship and allows the child to feel supported and understood. Choice A may overwhelm the child with unnecessary information. Choice C may hinder the nurse's ability to conduct a thorough examination. Choice D is inappropriate and may cause distress to the child.