ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
Correct Answer: B
Rationale: The correct answer is B: When part of the lung is obstructed or collapsed. Unequal chest expansion can occur when there is an obstruction or collapse of a portion of the lung, leading to decreased lung expansion on that side. This can result in one side of the chest moving less during breathing. Other options are incorrect because: A: In an obese patient - obesity may affect chest wall movement but does not directly cause unequal chest expansion. C: When bulging of the intercostal spaces is present - bulging of intercostal spaces may indicate increased work of breathing but does not necessarily lead to unequal chest expansion. D: When accessory muscles are used to augment respiratory effort - while accessory muscles may be used in respiratory distress, they do not directly cause unequal chest expansion.
Question 2 of 5
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities. A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.
Question 3 of 5
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
Correct Answer: B
Rationale: The correct answer is B because listening in a rough Z pattern allows the nurse to cover all areas where heart sounds can be best heard - aortic, pulmonic, tricuspid, and mitral. This technique ensures a systematic approach to auscultation, starting at the base of the heart and moving towards the apex where the mitral area is located. By inching the stethoscope in this pattern, the nurse can accurately identify any abnormalities in heart sounds. Choice A is incorrect as it does not provide a systematic approach to auscultation and may lead to missing certain areas. Choice C is incorrect as heart sounds should be listened to at all relevant areas, not just where the apical pulse is strongest. Choice D is incorrect as listening for all possible sounds at once may lead to confusion and missing subtle abnormalities.
Question 4 of 5
A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have?
Correct Answer: A
Rationale: The correct answer is A: Acute orchitis. Orchitis is inflammation of the testicle, commonly caused by a viral infection (e.g., mumps) or a bacterial infection. In this case, the teenager presents with a swollen, tender left testicle, redness, and fever. The history of recent upper respiratory symptoms suggests a viral cause. Epididymitis (choice B) typically presents with pain in the scrotum and inflammation of the epididymis. Torsion of the spermatic cord (choice C) is a surgical emergency with sudden onset severe pain, absent cremasteric reflex, and high-riding testicle. Prostatitis (choice D) presents with symptoms like dysuria, pelvic pain, and fever, but the prostate exam here is unremarkable. Therefore, based on the clinical presentation and examination findings, the most likely diagnosis is acute orchitis.
Question 5 of 5
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
Correct Answer: B
Rationale: The correct answer is B: Enlarged and tender inguinal nodes. Infections in the foot can lead to regional lymphadenopathy, causing enlargement and tenderness in the inguinal nodes closest to the affected area. This is a common sign of local infection. A: Hard and fixed cervical nodes are not typical findings for an infection in the foot. Cervical nodes are located in the neck and would not be directly affected by a foot infection. C: Bilateral enlargement of the popliteal nodes is not a common finding in foot infections. Popliteal nodes are located behind the knees and would not be directly involved in a foot infection. D: Pelletlike nodes in the supraclavicular region are not expected findings for a foot infection. Supraclavicular nodes are located in the neck and are not typically involved in a localized foot infection.