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: In this scenario, the correct answer is D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions. The presence of an enlarged right epitrochlear lymph node indicates a local inflammatory process or infection in the hand, lower arm, or fingers on the same side. By examining the lower arm and hand, the nurse can assess for signs of infection, lesions, or any other abnormalities that could be causing the lymph node enlargement. Option A is incorrect because assessing the abdomen for tenderness is not directly related to the finding of an enlarged epitrochlear lymph node. Option B is incorrect as assessing the cervical lymph nodes, while important in general assessment, is not the priority when a specific lymph node enlargement is noted. Option C is incorrect as asking about recent ear infections or sore throats is not likely to provide relevant information related to the localized finding of an enlarged epitrochlear lymph node. Educationally, understanding the significance of lymph node enlargement in specific locations and the importance of localizing the assessment to the affected area can help nurses make accurate clinical judgments and provide appropriate care to patients. It reinforces the importance of thorough physical assessment and the relevance of connecting assessment findings to potential underlying causes.
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: The correct answer is D) An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. This statement is accurate because a normal ABI ranges from 1.0 to 1.4, and a lower ABI suggests the presence of peripheral arterial disease. An ABI between 0.91 and 0.7 is considered borderline, indicating mild to moderate peripheral vascular disease and potential claudication. Option A is incorrect because normal ABI indices range from 1.0 to 1.4, not 0.5 to 1.0. Option B is incorrect as normal ankle pressure is expected to be higher than brachial pressure due to the hydrostatic pressure gradient in the lower extremities. Option C is incorrect because while ABI is a valuable tool in assessing peripheral vascular disease, it is not exclusive to individuals with diabetes but is applicable to a broader population. In an educational context, understanding ABI is crucial for nurses in assessing peripheral vascular disease, especially in patients with conditions like diabetes or hypertension. Correctly interpreting ABI results can aid in early detection, intervention, and prevention of complications related to vascular diseases, emphasizing the importance of accurate assessment and interpretation of vital signs in clinical practice.