ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D because it provides reassurance based on the typical age range for breast development in girls, which is between 8 and 10 years old. By stating this, the nurse acknowledges the girl's concerns and normalizes her experience. Option A is not as specific and may not address the girl's worries directly. Option B personalizes the response, which may not be helpful in this situation. Option C focuses on menstruation, which is not directly related to breast development and may cause unnecessary anxiety. In summary, option D is the best response as it provides accurate information and reassurance tailored to the girl's concerns.
Question 2 of 5
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:
Correct Answer: B
Rationale: The correct answer is B. Listening with the bell of the stethoscope allows the nurse to assess for bruits, abnormal sounds indicating turbulent blood flow in carotid arteries, which could indicate potential blockages or narrowing. Palpating the artery in the upper one third of the neck (A) is not recommended as it could potentially dislodge plaque and cause a stroke. Simultaneously palpating both arteries (C) is not necessary for this assessment. Instructing the patient to take slow deep breaths (D) is not relevant to assessing the carotid arteries for bruits.
Question 3 of 5
A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable. What abnormality of the scrotum does he most likely have?
Correct Answer: D
Rationale: The correct answer is D: Varicocele. Varicocele is the most likely abnormality in this case due to the presence of a "bag of worms" feeling upon palpation through the right inguinal ring, especially when the patient bears down. Varicocele is a dilation of the veins within the spermatic cord, leading to a mass resembling a bag of worms. The patient's symptoms of aching in the testicle that worsens throughout the day and improves in the morning are characteristic of varicocele, as increased intra-abdominal pressure exacerbates the symptoms. The absence of discrete masses on palpation and no bulges on bearing down help rule out other conditions like scrotal hernia. Hydrocele presents as a painless fluid-filled sac around the testicle, not a "bag of worms." Scrotal edema would present with swelling and pitting edema, which are not described in this case.
Question 4 of 5
Which vein(s) is(are) responsible for most of the venous return in the arm?
Correct Answer: D
Rationale: The correct answer is D: Superficial. The superficial veins, like the basilic and cephalic veins, are responsible for most of the venous return in the arm due to their larger size and proximity to the surface. These veins run parallel to major arteries, assisting in venous return through the pumping action of nearby muscles. Deep veins are important but less significant in venous return compared to superficial veins in the arm. Ulnar and subclavian veins are not primarily responsible for venous return in the arm.
Question 5 of 5
When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:
Correct Answer: D
Rationale: Step-by-step rationale for why the correct answer is D (Paradoxus): 1. Pulsus paradoxus is characterized by a decrease in pulse strength during inspiration and an increase during expiration, as seen in the patient's pulse assessment. 2. The blood pressure reading decreasing by 20 mm Hg during inspiration is indicative of pulsus paradoxus, as it reflects an exaggeration of the normal inspiratory drop in blood pressure. 3. Pulsus paradoxus is commonly associated with conditions like cardiac tamponade and severe asthma, which can cause this paradoxical pulse and blood pressure pattern. Summary of why the other choices are incorrect: A. Alternans: Alternating strong and weak pulse amplitudes, not related to the respiratory cycle. B. Bisferiens: Pulse with double systolic peaks, not related to respiratory cycle changes. C. Bigeminus: A pattern of every other heartbeat occurring prematurely, not related to respiratory cycle influences.