ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured?
Correct Answer: A
Rationale: Tympanic measures core temperature via the eardrum, close to the hypothalamus, per the answer key. Oral approximates core but varies with intake. Axillary and skin surface reflect peripheral temp, less accurate for core. Tympanic's proximity to central blood flow makes it reliable for quick, non-invasive core readings, aligning with nursing practice for accuracy in critical assessments, distinguishing it from less precise peripheral sites.
Question 2 of 5
A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area?
Correct Answer: D
Rationale: Tympany , per the answer key, is the hollow, drum-like tone over the air-filled stomach. Flat is over bone, dull organs, resonant lungs. Nurses, per Taylor, expect tympany in gastric percussion for normal assessment.
Question 3 of 5
A 24-year-old travel agent comes to your clinic, complaining of pain and swelling in her vulvar area. She states that 2 days earlier she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago and she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum, a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems?
Correct Answer: A
Rationale: The correct answer is A: Bartholin's gland infection. The patient's symptoms of pain, swelling, tenderness, and the presence of a red, tense swelling to the left of her introitus are classic signs of Bartholin's gland infection. The Bartholin's gland is located at the entrance to the vagina and can become infected, leading to the formation of a painful abscess. The patient's age, sexual activity, and use of contraception are all risk factors for developing this condition. The absence of systemic symptoms such as fever, along with the localized nature of the swelling, further support this diagnosis. The other choices are incorrect because: B: Vulvar carcinoma typically presents with different symptoms such as persistent itching, bleeding, or changes in the appearance of the skin. C: Secondary syphilis would present with systemic symptoms like rash, fever, and lymphadenopathy, which are absent in this case. D: Condylomata acuminata (genital warts) usually
Question 4 of 5
Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous?
Correct Answer: A
Rationale: The correct answer is A: About 10%. The risk of a breast mass being cancerous in a 48-year-old woman without any other information is approximately 10%. This estimate is based on epidemiological data and risk assessment tools that consider age, family history, and other risk factors. It is important to note that the risk could vary based on individual factors, but in general, the likelihood of a breast mass being cancerous is lower in younger women. Choices B, C, and D are incorrect as they overestimate the risk without considering the specific patient's characteristics.
Question 5 of 5
Which of the following percussion notes would you obtain over the gastric bubble?
Correct Answer: B
Rationale: The correct answer is B: Tympany. When percussing over the gastric bubble, you would expect to hear a tympanic sound due to the presence of gas in the stomach. Tympany is characterized by a drum-like, hollow sound. Resonance (A) is a normal lung sound, hyperresonance (C) is indicative of hyperinflation of the lungs, and flatness (D) is typically heard over solid organs or areas of consolidation in the lungs. Therefore, the presence of a gastric bubble would produce a tympanic note on percussion.