ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable. What visible skin change of the breast does she have?
Correct Answer: A
Rationale: The correct answer is A: Nipple retraction. Nipple retraction is characterized by the inward pulling of the nipple, which can be associated with underlying breast pathology such as breast cancer. In this case, a flattened nipple deviating towards the lateral side indicates nipple retraction, which is concerning for malignancy. Other choices are incorrect: B) Paget's disease presents with eczematous changes around the nipple; C) Peau d'orange sign refers to skin dimpling resembling an orange peel, seen in inflammatory breast cancer; D) No option provided.
Question 2 of 5
The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
Correct Answer: C
Rationale: Rationale for Correct Answer C: 1. Normal Aging Process: It is normal for older adults to take a little longer to respond due to age-related changes in cognitive processing speed. 2. General Knowledge and Abilities: The patient's general knowledge and abilities should not have declined significantly just due to age. 3. Overall Mental Status: Despite potential slower response times, the patient's mental status should be intact in terms of memory, attention, and orientation. Summary of Other Choices: A. Incorrect - Unrealistic expectation as aging typically results in some decline in cognitive abilities. B. Incorrect - While remote memory may decline with age, it is not a guarantee for all individuals. D. Incorrect - Response time may be slower, but loss of language and general knowledge is not necessarily expected solely due to age.
Question 3 of 5
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. This is because the patient's emotional response (laughing loudly) does not match the content of the picture (decapitated head), which is considered inappropriate. Confusion (A) refers to a lack of understanding, ambivalence (B) is conflicting feelings, and depersonalization (C) is feeling disconnected from oneself, none of which fully explain the patient's behavior. Inappropriate affect best describes the mismatch between the patient's emotional expression and the situation presented.
Question 4 of 5
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
Correct Answer: D
Rationale: The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.
Question 5 of 5
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Be mindful of the child's modesty. This is the most appropriate action because it respects the child's privacy and helps build trust. Starting with the genitalia (B) can be invasive and inappropriate. Talking about equipment (A) may not address the child's emotional needs. Performing a head-to-toe assessment starting with the chest (D) may overlook the importance of considering the child's comfort and modesty. Being mindful of modesty shows respect for the child's dignity and autonomy.