ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:
Correct Answer: B
Rationale: Rationale: Option B is correct because the nurse should gather more information to assess the patient's pain properly. This response shows active listening and empathy, facilitating a comprehensive evaluation. Option A is incorrect as it dismisses the patient's concern and provides inaccurate information about breast cancer. Option C is incorrect as it shifts the focus to the nurse's experience rather than addressing the patient's current situation. Option D is incorrect because while breast pain can be benign, assuming it is always benign without further assessment can lead to missed diagnoses.
Question 2 of 5
During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
Correct Answer: C
Rationale: The correct answer is C: Displacement of the heart from elevation of the diaphragm. During pregnancy, the growing uterus pushes the diaphragm upwards, causing the heart to be displaced upwards and laterally. This displacement results in the apical impulse being palpated at a higher position, such as the fourth left intercostal space lateral to the midclavicular line. This finding is a normal physiological change due to pregnancy and does not indicate any cardiac pathology. Explanation of other choices: A: Right ventricular hypertrophy - This is unlikely in a pregnant patient without underlying cardiac conditions. B: Increased volume and size of the heart as a result of pregnancy - While the heart may undergo some changes during pregnancy, palpating the apical impulse at a higher position is specifically due to displacement of the heart by the elevated diaphragm, not increased heart size. D: Increased blood flow through the internal mammary artery - This choice is unrelated to the displacement of the heart and the
Question 3 of 5
A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a 'bag of worms' in the left scrotum, superior to the testicles. Which of the following is most likely?
Correct Answer: B
Rationale: The correct answer is B: Varicocele. Varicocele is characterized by dilated and tortuous veins within the spermatic cord, giving a 'bag of worms' sensation. It typically occurs on the left side and is more common in young men. Rationale: 1. Hydrocele of the spermatic cord (A) presents as a fluid-filled sac around the spermatic cord, not as dilated veins. 2. Testicular carcinoma (C) typically presents as a painless lump within the testicle, not as dilated veins in the spermatic cord. 3. A normal vas deferens (D) is a normal part of the male reproductive anatomy and would not present as a 'bag of worms' sensation. In summary, the presence of dilated and tortuous veins in the left scrotum, superior to the testicles, is most indicative of a varicocele, making it the correct choice.
Question 4 of 5
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 5 seconds in an adult is considered delayed and may indicate poor perfusion or circulatory issues. The nurse should investigate further to determine the underlying cause. Option A is incorrect as frostbite history does not directly relate to the capillary refill time in this scenario. Option B is incorrect as venous insufficiency does not typically affect capillary refill time. Option D is incorrect because a capillary refill time of 5 seconds is not considered normal in adults and warrants further evaluation.
Question 5 of 5
A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom?
Correct Answer: C
Rationale: The correct answer is C: Cardiac. Shortness of breath is a common symptom of cardiac conditions such as heart failure or coronary artery disease. The heart plays a crucial role in pumping oxygenated blood to the body, so any dysfunction can lead to inadequate oxygen supply and result in shortness of breath. Reproductive (A), urinary (B), and hematologic (D) systems are not primarily responsible for regulating oxygen supply and are unlikely to directly cause shortness of breath.