ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
Correct Answer: B
Rationale: The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management. Incorrect choices: A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold. C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent. D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.
Question 2 of 5
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Correct Answer: A
Rationale: Rationale: Position A (Supine with the arms raised over her head) is most likely to make significant lumps more distinct during breast palpation because raising the arms stretches the breast tissue, making abnormalities easier to feel. This position allows for better access to all areas of the breast. In contrast, choices B (Sitting with the arms relaxed at her sides) and C (Supine with the arms relaxed at her sides) do not provide the same level of breast tissue stretching, making it harder to detect lumps. Choice D (Sitting with the arms flexed and fingertips touching her shoulders) may limit the nurse's ability to fully palpate the breast due to the arms being in the way.
Question 3 of 5
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
Correct Answer: B
Rationale: The correct answer is B: Blood flow turbulence. The blowing, swishing sound heard over the left carotid artery indicates a bruit, which is caused by turbulent blood flow. This can be due to atherosclerosis or stenosis in the carotid artery. Increased cardiac output (A) would not manifest as a bruit. Fluid volume overload (C) would not cause a bruit specifically over the carotid artery. Ventricular hypertrophy (D) is unrelated to the presence of a bruit. In summary, the presence of a bruit indicates blood flow turbulence, typically due to underlying vascular pathology.
Question 4 of 5
A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Scrotal edema. The patient's presentation of a swollen scrotum that worsens with standing and improves with lying down is consistent with scrotal edema, which is often associated with fluid accumulation due to conditions like heart failure, renal failure, or liver disease. The patient's history of high blood pressure, coronary artery disease, and shortness of breath with exertion suggest possible heart failure as the underlying cause. The absence of bulges with bearing down rules out a scrotal hernia. Hydrocele presents as a painless collection of fluid around the testicle, typically without systemic symptoms. Varicocele is a dilatation of the veins in the scrotum, usually described as a "bag of worms" sensation, and is not typically associated with the patient's symptoms.
Question 5 of 5
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, 'What happens to my circulation when this vein is removed?' The nurse should reply:
Correct Answer: D
Rationale: Rationale for Correct Answer D: 1. The great saphenous vein is a superficial vein and removal doesn't significantly impact circulation. 2. Deeper veins, like the femoral and popliteal veins, are responsible for major venous return. 3. These deeper veins will compensate for the removal of the great saphenous vein, maintaining circulation. 4. Therefore, removing the great saphenous vein won't harm circulation due to the presence of deeper veins. Summary of Incorrect Choices: A: Incorrect. Venous insufficiency isn't a common problem post-surgery as other veins compensate. B: Incorrect. Dismissing the significance of vein removal and its impact on circulation is inaccurate. C: Incorrect. While there may be decreased circulation in the superficial system, deep venous return is preserved.