ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
Correct Answer: A
Rationale: The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk), may be expressed from the breasts.
Question 2 of 5
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
Correct Answer: C
Rationale: Studies show that percussed cardiac borders do not correlate well with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargement.
Question 3 of 5
A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup. What is the most likely diagnosis for this young man's symptoms?
Correct Answer: C
Rationale: Torsion is caused by the twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle's function is lost and it has to be removed. The presence of a cremasteric reflex is reassuring, but in this case a thorough evaluation must take place as soon as possible.
Question 4 of 5
When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.