ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A nurse educator is teaching a patient about a healthy diet. What information would be included to reduce the risk of hypertension?
Correct Answer: D
Rationale: In the context of reducing the risk of hypertension, the correct answer is D) Put away the salt shaker and eat low-salt foods. Excessive sodium intake is strongly linked to high blood pressure, so reducing salt consumption is crucial in managing and preventing hypertension. By avoiding high-salt foods and using less salt in cooking, blood pressure can be better controlled. Option A) Eat a diet high in fruits and vegetables is beneficial for overall health, but it doesn't directly address the issue of sodium intake which is key in hypertension management. Option B) Remember to drink 8 to 10 glasses of water a day is important for hydration but doesn't specifically target hypertension. Option C) It is important to have increased fats in your diet is misleading as high-fat diets can contribute to heart disease and obesity, which are risk factors for hypertension. In an educational context, it's essential to emphasize the impact of lifestyle choices on health outcomes. Teaching patients about the relationship between salt intake and hypertension empowers them to make informed dietary decisions. Encouraging the adoption of a low-salt diet can be a practical and effective strategy in hypertension management.
Question 2 of 5
A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings?
Correct Answer: C
Rationale: The correct answer is C: Bacterial vaginosis. The clinical presentation of a thin gray-white discharge with a fishy odor, pH over 4.5, presence of clue cells on wet prep, and increased smell after intercourse are classic signs of bacterial vaginosis. Trichomonas vaginitis (choice A) typically presents with a frothy, yellow-green discharge and itching. Candida vaginitis (choice B) presents with a thick, white cottage cheese-like discharge and itching. Atrophic vaginitis (choice D) is more common in postmenopausal women due to estrogen deficiency and presents with vaginal dryness and dyspareunia. In this case, the patient's symptoms and exam findings are most consistent with bacterial vaginosis based on the Amsel criteria (thin gray-white discharge, pH over 4.5, fishy odor, clue cells).
Question 3 of 5
A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable. Which risk factor of her personal and family history most puts her in danger of getting breast cancer?
Correct Answer: A
Rationale: The correct answer is A: First-degree relative with premenopausal breast cancer. This is the most significant risk factor for the patient because her sister had unilateral breast cancer at a young age of 38, which indicates a potential genetic predisposition. Having a first-degree relative with premenopausal breast cancer significantly increases the patient's risk due to shared genetic factors. The other choices are less significant: B: Age at menarche of less than 12 is a risk factor, but not as significant as a family history of breast cancer. C: First live birth between the ages of 25 and 29 is actually a protective factor against breast cancer, as early pregnancies can reduce the risk. D: First-degree relative with postmenopausal breast cancer is a risk factor, but premenopausal breast cancer in a first-degree relative is a stronger indicator of genetic risk. In summary, the patient's highest risk factor for developing breast cancer is having a first-degree relative with
Question 4 of 5
A 60-year-old baker presents with increasing shortness of breath and nonproductive cough over the last month. She has to sleep upright in her recliner. On examination, she has distant air sounds and late inspiratory crackles in both lower lobes.
Correct Answer: D
Rationale: The correct answer is D, left-sided heart failure. The patient's symptoms of shortness of breath, nonproductive cough, orthopnea, distant air sounds, and crackles in both lower lobes are indicative of congestive heart failure (CHF). In CHF, the heart is unable to pump effectively, causing fluid buildup in the lungs (pulmonary edema) leading to symptoms like orthopnea and crackles on auscultation. This is known as cardiogenic pulmonary edema. The absence of fever or sputum production makes pneumonia less likely (choice A). While COPD (choice B) can present with similar symptoms, the absence of a history of smoking or exposure to risk factors makes it less likely. Pleural pain (choice C) is typically associated with sharp chest pain worsened by breathing or coughing, which is not described in this case.
Question 5 of 5
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:
Correct Answer: A
Rationale: The correct answer is A: Plan to defer the rest of the mental status examination. Given the patient's dysarthric speech and lethargy, it is essential to prioritize the patient's physical well-being and safety over completing the mental status examination. Dysarthric speech may indicate a potential neurological issue that needs immediate attention. Deferring the examination allows for a more thorough assessment once the patient's physical condition stabilizes. Choice B is incorrect because skipping the language portion and proceeding to mood and affect assessment neglects the importance of addressing the potential underlying medical issue causing the dysarthric speech. Choice C is incorrect because conducting an in-depth speech evaluation and deferring the mental status examination may delay necessary medical intervention for the patient's condition. Choice D is incorrect because assuming dysarthria is always associated with severe depression and jumping to assess for suicidal thoughts without addressing the immediate physical concerns is premature and may lead to overlooking critical medical issues.