ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?
Correct Answer: B
Rationale: Answer B is correct because assessing the girl's weight and BMI is important to determine if early breast budding is related to precocious puberty, which can be influenced by weight. Option A is not appropriate as periods starting is not directly relevant to early breast development. Option C focuses on the mother's history, not the current girl's situation. Option D is incorrect as further evaluation is needed to rule out any underlying health issues.
Question 2 of 5
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because watching the patient's respirations while listening for the effect on the sound can help differentiate between an S3 and an opening snap or ejection sound. Observing how the sound changes with the respiratory cycle can provide valuable information about the origin and nature of the sound. Choice A is incorrect because having the patient turn to the left side with the bell of the stethoscope is typically done to enhance the detection of a mitral murmur, not to assess a sound immediately after S2. Choice B is incorrect because asking the patient to hold their breath is more relevant in assessing for a pericardial friction rub, not in differentiating between heart sounds. Choice C is incorrect because assuming the sound is an S3 without further assessment can lead to a misdiagnosis. It is essential to confirm the nature of the sound through appropriate assessment techniques.
Question 3 of 5
Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?
Correct Answer: B
Rationale: The correct answer is B: Paraphimosis. This condition occurs when the foreskin is retracted behind the glans and becomes trapped, leading to swelling and an inability to return it to its original position. Phimosis (A) is the inability to retract the foreskin over the glans. Balanitis (C) is inflammation of the glans while Balanoposthitis (D) is inflammation of both the glans and foreskin. Paraphimosis specifically refers to the foreskin being stuck in a retracted position, making it the correct choice.
Question 4 of 5
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
Correct Answer: A
Rationale: The correct answer is A: Claudication. This patient is likely experiencing intermittent claudication, which is pain or discomfort in the muscles of the leg, typically the calf, that occurs during physical activity and is relieved by rest. The key clues in the question are the pain in the left calf specifically with activity (climbing stairs), relief with rest, and the patient's age of 67 which is a risk factor for peripheral artery disease (PAD) leading to claudication. Sore muscles (B) and muscle cramps (C) do not typically present with this pattern of pain and relief. Venous insufficiency (D) usually manifests with swelling, skin changes, and may worsen with prolonged standing, not specifically with activity like in this case.
Question 5 of 5
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
Correct Answer: B
Rationale: The correct answer is B: Raynaud disease. This condition is characterized by a triphasic color change in the fingers (white, blue, red) due to vasospasms in response to cold or stress. The white color indicates decreased blood flow, the blue color is due to lack of oxygen, and the red color signifies reactive hyperemia. The burning, throbbing pain is also a common symptom. Lymphedema (A) is swelling due to lymphatic system dysfunction, not color changes. Deep-vein thrombosis (C) involves blood clots in the deep veins, not color changes. Chronic arterial insufficiency (D) would typically present with a pale or dusky color due to reduced blood flow, rather than the described color changes.