ATI RN
Vital Signs Assessment Questions
Question 1 of 5
A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence. What disorder of the axilla is most likely responsible for her symptoms?
Correct Answer: A
Rationale: The correct answer is A: Breast cancer. The presence of an enlarged, hard, fixed lymph node in the right axilla, along with a nontender lump in the tail of Spence (an area of the breast where breast cancer commonly occurs), strongly suggests breast cancer as the most likely cause. The patient's age, gender, history of smoking, and lack of breast self-exams increase her risk for breast cancer. The absence of tenderness in the lymph node also raises suspicion. Other choices are less likely: B (lymphadenopathy of infectious origin) would typically present with other symptoms like fever or localized infection; C (hidradenitis suppurativa) is a chronic skin condition affecting the sweat glands, not typically presenting with an enlarged lymph node. The patient's history and examination findings align more with breast cancer.
Question 2 of 5
The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
Correct Answer: C
Rationale: The correct answer is C: "I never did too good in school." This statement indicates potential underlying issues like learning disabilities or lack of education, affecting the patient's understanding of health information. The nurse should explore this further to assess the patient's health literacy. Choices A, B, and D are less critical as they do not directly impact the patient's health status or the interview process.
Question 3 of 5
The nurse makes which adjustment in the physical environment to promote the success of an interview?
Correct Answer: A
Rationale: The correct answer is A because reducing noise helps create a conducive environment for effective communication during the interview. Noise can be distracting and hinder the patient's ability to focus and share information. Turning off televisions and radios promotes a quiet and focused setting. Choice B is incorrect because reducing the distance between the interviewer and the patient to 2 feet or less may invade the patient's personal space and make them uncomfortable. Choice C is incorrect as dim lighting may not be suitable for all patients and can affect visibility and communication. Choice D is incorrect because arranging seating across a desk or table can create a barrier and may not allow for a comfortable and open conversation.
Question 4 of 5
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
Correct Answer: B
Rationale: The correct answer is B: Takes time and reveals a surprising amount of information. During the inspection phase of a physical assessment, the nurse carefully observes the patient's appearance, behavior, and movements. This phase is crucial as it provides valuable visual information about the patient's overall health status, potential abnormalities, and clues for further assessment. By taking time and paying attention to detail during inspection, the nurse can gather significant data that can guide the rest of the assessment process. The other choices are incorrect because: A) Inspecting usually yields valuable information, C) Discomfort is not a typical characteristic of the inspection phase, and D) Inspection requires thorough observation, not just a quick glance before palpation.
Question 5 of 5
When using an otoscope to examine a patient, the nurse:
Correct Answer: C
Rationale: The correct answer is C because when using an otoscope, the nurse should direct light onto the tympanic membrane (eardrum) to visualize its condition. This helps in assessing ear health and identifying any abnormalities or infections. Choice A is incorrect as an otoscope is not used to visualize sinuses. Choice B is incorrect as it refers to examining inner ear structures which is beyond the scope of an otoscope. Choice D is incorrect as external lesions are not typically assessed using an otoscope.