ATI RN
PN Vital Signs Assessment Questions
Question 1 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 2 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 3 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 4 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 5 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.