ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale: The correct answer is C: Maxillary sinusitis. The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and pain in the cheeks and teeth on one side with palpation are indicative of maxillary sinusitis. The maxillary sinuses are located in the cheekbones, and inflammation can lead to these specific symptoms. Posterior epistaxis (A) refers to bleeding from the back of the nose, which is not consistent with the patient's symptoms. Frontal sinusitis (B) would present with symptoms in the forehead region, not in the cheeks and teeth. Nasal polyps (D) are growths in the nasal passages and usually do not cause the specific symptoms described in the case.
Question 2 of 5
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? The nurse should tell her that:
Correct Answer: C
Rationale: The correct answer is C because cyclic breast changes are common due to hormonal fluctuations during the monthly menstrual cycle. This is a normal physiological process where breasts may feel different at different times of the month. It is important for the nurse to reassure the woman that these changes are normal. Choice A is incorrect as it states that continual changes in breasts are unusual, which is not accurate for nonpregnant women. Choice B is incorrect as it focuses on stress as the cause of breast changes, which is not the primary reason in this case. Choice D is incorrect as it suggests that breast changes only occur during pregnancy, which is not true as hormonal fluctuations during the menstrual cycle can also cause changes in breasts.
Question 3 of 5
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:
Correct Answer: B
Rationale: The correct answer is B. Palpating the unaffected breast first allows for establishing a baseline for comparison, aiding in identifying any differences in texture, size, or tenderness. This approach helps in assessing the lump in the left breast effectively. Palpating the affected breast first (choice A) may lead to missing important comparisons. Avoiding palpation due to potential cyst rupture (choice C) is incorrect as palpation is necessary for assessment. Palpating the breast with the lump first but the axilla last (choice D) is not ideal as it doesn't prioritize establishing a baseline for accurate assessment.
Question 4 of 5
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
Correct Answer: D
Rationale: The correct answer is D: Fifth left intercostal space at the midclavicular line. The apical impulse, also known as the point of maximal impulse (PMI), is the point on the chest wall where the heartbeat is most easily palpated. It is normally located at the fifth intercostal space at the midclavicular line, which aligns with the apex of the heart. Palpating this area allows the nurse to assess the location, size, and strength of the heartbeat. Choices A, B, and C are incorrect because they do not correspond to the typical location of the apical impulse.
Question 5 of 5
A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case?
Correct Answer: B
Rationale: The correct answer is B: Acute epididymitis. Epididymitis is characterized by pain, swelling, and inflammation of the epididymis, which is located next to the testicle. In this case, the patient's symptoms of testicular pain, pain with urination, and tenderness at the superior pole of the left testicle are classic signs of epididymitis. The presence of white blood cells and bacteria in the urine analysis further supports the diagnosis of an infectious process in the genitourinary tract. Acute orchitis (choice A) involves inflammation of the testicle itself, without the characteristic tenderness of the epididymis. Torsion of the spermatic cord (choice C) typically presents with sudden severe testicular pain and swelling, with absent cremasteric reflex. Prostatitis (choice D) would present with symptoms related to the prostate gland, such as perineal or pelvic pain, not the testicle and penis.