ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
Correct Answer: D
Rationale: The correct response is D. Using nasal medications can irritate the nasal lining, leading to rebound swelling, which causes the medication to become less effective over time. This explains why the woman's nasal spray is not working as well as before. It is important for the nurse to address this issue to prevent worsening of symptoms. Choice A is incorrect as not all over-the-counter nasal sprays carry a risk of addiction. Choice B is not the best response as switching brands may not address the underlying issue of rebound swelling. Choice C is incorrect as it does not address the potential problem of rebound swelling caused by the nasal spray.
Question 2 of 5
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? Tell the mother that:
Correct Answer: C
Rationale: The correct answer is C because unilateral breast enlargement with tenderness in a 10-year-old girl is most likely due to normal breast development, known as thelarche. The nurse should reassure the mother that it is common for breast development to be asymmetric initially and that an examination can confirm this. This response is appropriate because breast cancer is extremely rare in preadolescent girls, making option B incorrect. Option A is incorrect as immediate examination is not necessary unless there are other concerning symptoms. Option D is incorrect as breast tenderness can occur during breast development due to hormonal changes. Thus, option C is the best response based on the presentation and age of the patient.
Question 3 of 5
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Correct Answer: A
Rationale: Rationale: Position A (Supine with the arms raised over her head) is most likely to make significant lumps more distinct during breast palpation because raising the arms stretches the breast tissue, making abnormalities easier to feel. This position allows for better access to all areas of the breast. In contrast, choices B (Sitting with the arms relaxed at her sides) and C (Supine with the arms relaxed at her sides) do not provide the same level of breast tissue stretching, making it harder to detect lumps. Choice D (Sitting with the arms flexed and fingertips touching her shoulders) may limit the nurse's ability to fully palpate the breast due to the arms being in the way.
Question 4 of 5
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
Correct Answer: B
Rationale: The correct answer is B: Blood flow turbulence. The blowing, swishing sound heard over the left carotid artery indicates a bruit, which is caused by turbulent blood flow. This can be due to atherosclerosis or stenosis in the carotid artery. Increased cardiac output (A) would not manifest as a bruit. Fluid volume overload (C) would not cause a bruit specifically over the carotid artery. Ventricular hypertrophy (D) is unrelated to the presence of a bruit. In summary, the presence of a bruit indicates blood flow turbulence, typically due to underlying vascular pathology.
Question 5 of 5
A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Scrotal edema. The patient's presentation of a swollen scrotum that worsens with standing and improves with lying down is consistent with scrotal edema, which is often associated with fluid accumulation due to conditions like heart failure, renal failure, or liver disease. The patient's history of high blood pressure, coronary artery disease, and shortness of breath with exertion suggest possible heart failure as the underlying cause. The absence of bulges with bearing down rules out a scrotal hernia. Hydrocele presents as a painless collection of fluid around the testicle, typically without systemic symptoms. Varicocele is a dilatation of the veins in the scrotum, usually described as a "bag of worms" sensation, and is not typically associated with the patient's symptoms.