ATI RN
Vital Signs and Pain Assessment Questions
Question 1 of 5
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of:
Correct Answer: B
Rationale: The correct answer is B) Increased vascularity in the upper respiratory tract as a result of pregnancy. During pregnancy, hormonal changes lead to an increase in blood volume and circulation, causing the blood vessels in the upper respiratory tract to become more dilated and fragile. This increased vascularity can result in common pregnancy symptoms such as nasal congestion, nosebleeds, and nasal stuffiness. Option A) A problem with the patient's coagulation system is incorrect because nosebleeds during pregnancy are typically due to increased vascularity rather than a coagulation disorder. Option C) Increased susceptibility to colds and nasal irritation is not the primary reason for nosebleeds in pregnancy. While pregnant women may be more prone to respiratory infections, the increased vascularity is the main factor contributing to nosebleeds. Option D) Inappropriate use of nasal sprays is not the cause in this scenario unless the woman is using nasal sprays excessively or inappropriately. However, the most likely reason for her nosebleeds is the physiological changes related to pregnancy. Educationally, understanding the physiological changes that occur during pregnancy and their impact on various body systems, including the respiratory system, is crucial for healthcare providers to provide appropriate care and support to pregnant individuals. Recognizing common symptoms like nosebleeds as a result of increased vascularity can help nurses and other healthcare professionals address these issues effectively and reassure patients that they are experiencing normal pregnancy-related changes.
Question 2 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 3 of 5
The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation?
Correct Answer: C
Rationale: In this scenario, the missing information from the documentation is the size of the lump (Option C). Understanding the size of a breast lump is crucial in assessing its significance and determining the appropriate course of action. Size helps in categorizing the lump as small, medium, or large, which is essential in clinical decision-making. Option A (Shape of the lump) and Option B (Consistency of the lump) are important aspects of a thorough breast examination, but in this case, the key missing detail is the size of the lump. Knowing whether the lump is solitary or multiple (Option D) is also relevant but is secondary to determining the size, which is more critical for clinical assessment and follow-up. Educationally, emphasizing the importance of documenting the size of a breast lump helps students and healthcare providers understand the significance of this detail in the overall assessment of breast health. It highlights the need for comprehensive documentation to ensure accurate communication and appropriate patient care.
Question 4 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 5 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.