ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
Correct Answer: D
Rationale: Step 1: After menopause, hormonal changes lead to a decrease in estrogen levels. Step 2: Decreased estrogen causes glandular and fat tissue in the breasts to atrophy. Step 3: Atrophy of glandular and fat tissue results in diminished breast size and elasticity. Step 4: Diminished size and elasticity lead to breasts sagging. Step 5: Therefore, option D is correct as it accurately explains the physiological process behind breast sagging after menopause. Summary: Option A is incorrect as breast sagging can occur in women with any breast size. Option B is incorrect as breast sagging is not primarily due to decreased muscle mass. Option C is incorrect as protein intake does not directly prevent breast sagging caused by tissue atrophy.
Question 2 of 5
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?
Correct Answer: C
Rationale: The correct answer is C: No further response is needed because sinus arrhythmia can occur normally. Sinus arrhythmia is a common finding in young individuals, characterized by a variation in heart rate with respiration. In this case, the irregular rhythm of the apical pulse with speeding up on inspiration and slowing on expiration is consistent with sinus arrhythmia. It is a benign condition and does not require further intervention. Options A and D are incorrect as they are unnecessary and may cause unnecessary worry for the patient. Option B is also unnecessary at this point as the irregular rhythm is likely due to sinus arrhythmia and does not require immediate ECG confirmation.
Question 3 of 5
A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be?
Correct Answer: D
Rationale: The correct answer is D: Epidermoid cysts. Epidermoid cysts are common benign cysts that can occur on the scrotum. In this case, the description of firm, nontender yellow nodules on the scrotum fits with the presentation of epidermoid cysts. The patient's history of gradual growth and lack of associated symptoms such as pain or systemic symptoms also support this diagnosis. Condylomata acuminata (choice A) are genital warts caused by HPV and typically present as soft, pink, or grayish growths. Syphilitic chancre (choice B) is a painless ulcer caused by syphilis, which would not present as yellow nodules. Peyronie's disease (choice C) involves curvature of the penis and is not related to scrotal nodules. Therefore, based on the presentation and characteristics of the lesions, epidermoid cysts are the most likely diagnosis.
Question 4 of 5
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Presence of palpable lymph nodes. In children, lymph nodes are more superficial and easily palpable due to their higher metabolic rate and active immune system. This is a normal finding in healthy children. Excessive swelling of lymph nodes (A) would indicate an abnormal response to infection. The absence of palpable nodes (C) is not expected as even in young children, lymph nodes are palpable. Having fewer and smaller lymph nodes (D) is not typical in healthy children and would be concerning for an underlying issue.
Question 5 of 5
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?
Correct Answer: C
Rationale: The correct answer is C: Swishing, whooshing sound. This sound indicates venous flow in Doppler ultrasonic stethoscope. Venous flow produces a continuous, swishing sound due to the irregularity of blood flow in veins. Option A, a low humming sound, does not accurately represent venous flow. Option B, a regular 'lub, dub' pattern, is typical of normal heart sounds. Option D, a steady, even, flowing sound, does not reflect the nature of venous flow, which is more turbulent and irregular.