ATI RN
PN Vital Signs Assessment Questions
Question 1 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 2 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.
Question 3 of 5
The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
Correct Answer: B
Rationale: The correct answer is B: "The flow of lymph is slow, compared with that of the blood." Rationale: 1. Lymphatic vessels lack a central pump like the heart, which results in slower lymph flow compared to blood flow. 2. The slow movement allows for thorough filtration and immune surveillance within lymph nodes. 3. The statement reflects an accurate understanding of the physiological differences between the lymphatic and circulatory systems. Summary: A: Incorrect - Lymph flow is not propelled by the contraction of the heart; it is propelled by skeletal muscle contractions and respiratory movements. C: Incorrect - Lymph's main function is to collect excess tissue fluid and return it to the bloodstream, not to absorb lipids from the biliary tract. D: Incorrect - Lymph vessels do have one-way valves that prevent backflow, ensuring the proper direction of lymph flow.
Question 4 of 5
During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?
Correct Answer: B
Rationale: The correct answer is B: Lymphedema. Lymphedema is a condition characterized by swelling due to lymphatic system blockage or damage, commonly seen after mastectomy. In this case, the swelling is unilateral and nonpitting, typical of lymphedema. Venous stasis (A) usually presents with bilateral swelling and pitting edema. Arteriosclerosis (C) typically manifests with decreased or absent pulses and cool skin. Deep-vein thrombosis (D) presents with unilateral swelling and pain, but is usually pitting.
Question 5 of 5
A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?
Correct Answer: C
Rationale: The correct answer is C: Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. Rationale: 1. BMI of 26.0 kg/m2 indicates the patient is overweight, not underweight (anorexic) (Choice A) or obese (Choice D). 2. Patient's concern about weight indicates the need for guidance on healthy habits. 3. Providing information on reducing fat, cholesterol, and calories aligns with addressing weight concerns. Incorrect Choices: A: Refer the patient to a nutritionist because he is anorexic - Incorrect because the patient is overweight, not anorexic. B: Reassure the patient that he has a normal body weight - Incorrect as BMI of 26.0 kg/m2 indicates overweight, not normal weight. D: Give the patient information about reduction of fat and cholesterol because he is obese - Incorrect as the patient is overweight, not obese.