ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
During an annual examination, a girl states that she is concerned about her development. She asks the nurse when she will get breasts. In obtaining a health history, the nurse should ascertain which of the following? The age that:
Correct Answer: A
Rationale: The correct answer is A: The girl began to develop breasts. This is crucial to determine her stage of puberty. Breast development typically starts before other secondary sexual characteristics, making it a key indicator. Knowing the age of breast development helps assess if she is within the normal range or needs further evaluation. B: Her mother developed breasts - irrelevant to the girl's current development. C: She began to develop pubic hair - secondary sexual characteristic but not as indicative as breast development. D: She began to develop axillary hair - less reliable marker of puberty compared to breast development.
Question 2 of 5
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
Correct Answer: D
Rationale: The forceful movement along the sternal border indicates right ventricular enlargement. This is because the right ventricle is located close to the sternum. Enlargement of the left ventricle (Choice C) typically causes a sustained apical impulse. A systolic murmur (Choice B) is usually heard during auscultation, not observed visually. A normal heart (Choice A) would not exhibit forceful movement along the sternal border. Therefore, the correct answer is D.
Question 3 of 5
A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have?
Correct Answer: A
Rationale: The correct answer is A: Hydrocele. A hydrocele is a fluid-filled sac surrounding the testicle that typically presents as a painless mass in the scrotum. In this case, the patient's presentation of a painless, soft, cystic-like lesion over the right testicle is consistent with a hydrocele. The absence of other concerning symptoms like weight loss, fever, or night sweats also points towards a benign condition like hydrocele. The lack of difficulty with inguinal ring passage and absence of bulges with weight bearing rule out a scrotal hernia. Testicular tumor typically presents with different characteristics such as testicular pain or hard, irregular masses. Varicocele is characterized by enlarged veins in the scrotum, not a fluid-filled sac. Therefore, based on the patient's presentation and physical examination findings, the most likely diagnosis is a hydrocele.
Question 4 of 5
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
Correct Answer: B
Rationale: The correct answer is B because prolonged bed rest can lead to decreased muscle contraction in the legs, slowing blood flow and increasing the risk of venous stasis and clot formation. This increases the risk of developing venous disease. A: Pregnancy increases pressure on veins but typically resolves postpartum. C: Smoking is a risk factor for arterial disease, not venous disease. D: Anticoagulants are used to prevent clot formation, reducing the risk of venous disease. In summary, choice B is correct because prolonged bed rest directly contributes to venous stasis and clot formation, making it the highest risk factor among the options provided.
Question 5 of 5
During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel 'heavy in the calf' and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
Correct Answer: B
Rationale: The correct answer is B: Varicose veins. The woman's symptoms of heavy legs, foot cramps, and dilated, tortuous veins in the lower legs are classic signs of varicose veins. Varicose veins occur due to weakened valves in the veins, leading to pooling of blood and vein enlargement. Deep-vein thrombophlebitis (choice A) presents with redness, warmth, and swelling in the affected limb, which are not mentioned. Lymphedema (choice C) is characterized by persistent swelling, typically in one limb, due to lymphatic system dysfunction, not dilated veins. Raynaud phenomenon (choice D) involves episodes of reduced blood flow to extremities, causing color changes and numbness, which are not indicated in this scenario.