ATI RN
Assess Vital Signs Questions
Question 1 of 5
A nurse is preparing a patient for a physical assessment. The patient appears anxious about the assessment. Which statement by the nurse would be most appropriate?
Correct Answer: C
Rationale: Explaining the process , per the answer key, reduces anxiety by informing the patient, assuring no pain. Dismissal , warning of pain , or demanding relaxation increase distress. Nurses, per Taylor, prioritize communication to ease fears during assessments.
Question 2 of 5
A 22-year-old architecture major comes to your office, complaining of severe burning with urination, a fever of 101 degrees, and aching all over. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of severe acne. She is currently on an oral contraceptive. She has had no pregnancies or surgeries. She reports one new partner within the last month. She does not smoke but does drink occasionally. Her parents are both in good health. On examination you see a young woman appearing slightly ill. Her temperature is 100.3 and her pulse and blood pressure are unremarkable. Her head, ears, eyes, nose, throat, cardiac, pulmonary, and abdominal examinations are unremarkable. Palpation of the inguinal nodes shows lymphadenopathy bilaterally. On visualization of the perineum there are more than 10 shallow ulcers along each side of the vulva. Speculum and bimanual examination are unremarkable for findings, although she is very tender at the introitus. Urine analysis has some white blood cells but no red blood cells or bacteria. Her urine pregnancy test is negative. Which disorder of the vulva is most likely in this case?
Correct Answer: A
Rationale: The correct answer is A: Genital herpes. The clinical presentation of severe burning with urination, fever, aching all over, lymphadenopathy, and multiple shallow ulcers along the vulva is highly suggestive of genital herpes. The history of a new sexual partner and the absence of upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms further support this diagnosis. The presence of white blood cells in the urine is consistent with the systemic inflammatory response seen in genital herpes. The negative urine pregnancy test rules out pregnancy-related complications. Condylomata acuminata (choice B) presents as warty growths, not ulcers. Syphilitic chancre (choice C) typically presents as a painless ulcer with regional lymphadenopathy. Epidermoid cyst (choice D) does not typically cause symptoms like severe burning with urination and fever.
Question 3 of 5
A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?
Correct Answer: B
Rationale: The correct answer is B: Lymphadenopathy of infectious origin. The patient's presentation of a painful, tender, movable lymph node in the left axilla, associated with a tense red area and a scabbed-over superficial laceration on the left hand, suggests an inflammatory response due to an infection. The history of recent cut from gardening increases the likelihood of an infectious etiology. Breast cancer (choice A) is less likely given the acuity of symptoms, lack of breast abnormalities on examination, and the presence of a clear inciting event. Hidradenitis suppurativa (choice C) typically presents with recurrent painful nodules in areas with apocrine sweat glands, not usually associated with enlarged and tender lymph nodes. Choice D is not provided.
Question 4 of 5
A 75-year-old retired teacher presents with severe, unrelenting anterior chest pain radiating to her back, described as 'ripping out her heart.' Blood pressure is 180/110 in the right arm and 130/60 in the left arm, with asymmetric carotid pulses.
Correct Answer: C
Rationale: The correct answer is C: Dissecting aortic aneurysm. The patient's presentation is consistent with aortic dissection due to severe chest pain radiating to the back, asymmetric blood pressure in both arms, and asymmetric pulses. Aortic dissection is a life-threatening emergency requiring immediate intervention. Angina pectoris typically does not present with asymmetric blood pressure or pulses. Pericarditis usually presents with chest pain that worsens with deep breathing and is relieved by sitting up. Pleural pain is typically localized and not associated with asymmetric blood pressure or pulses.
Question 5 of 5
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action?
Correct Answer: A
Rationale: The correct answer is A: Perform a complete mental status examination. This is the best course of action as memory loss following a fall can be indicative of a serious condition such as a concussion or traumatic brain injury. A complete mental status examination will help assess various cognitive functions such as memory, orientation, attention, and reasoning abilities. This will provide a comprehensive evaluation of the husband's mental health and cognitive functioning, helping to identify any underlying issues that may require further intervention or treatment. Choice B is incorrect because a psychometrician typically focuses on administering and interpreting psychological tests, which may not address the immediate concerns related to memory loss after a fall. Choice C is not the best course of action as integrating the mental status examination into the history and physical examination may not provide a thorough assessment of the husband's cognitive abilities. Choice D is incorrect as memory loss after a physical shock should not be dismissed without a proper evaluation, as it could be a symptom of a more serious condition.