ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
Correct Answer: B
Rationale: The correct answer is B: A bifid uvula may occur in some Native-American groups. A bifid uvula refers to a split or forked uvula, which is a variation of normal anatomy and can be seen in certain populations, including some Native-American groups. This condition is usually benign and does not typically cause any health issues. It is important for healthcare providers to be aware of such variations to avoid unnecessary concern or intervention. Explanation for incorrect options: A: This condition is not a cleft palate, which is a more severe congenital condition involving a gap in the roof of the mouth. C: There is no indication that the bifid uvula is due to an injury or that it should be reported to authorities. D: "Palatinus" is not a term commonly used to describe a bifid uvula, and the statement about its frequency in Native Americans is not supported by evidence.
Question 2 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 3 of 5
Which of these clinical situations would the nurse consider to be outside normal limits?
Correct Answer: D
Rationale: The correct answer is D because the presence of thick yellow discharge from both nipples in a patient who has had two pregnancies and breastfed her children is outside the normal limits. This could indicate a condition such as galactorrhea, which is abnormal lactation unrelated to breastfeeding. The discharge may be due to hormonal imbalances or other underlying issues that require further investigation. Explanation for other choices: A: Soft and slightly sagging breasts in a patient entering menopause can be considered within normal limits due to hormonal changes. B: Firm, transverse ridges along the lower quadrant of breasts in a patient who has never been pregnant may indicate fibrocystic changes, which are common and typically not concerning. C: Nodular and engorged breast tissue with slight pain before menstruation is a common premenstrual symptom and is usually within normal limits.
Question 4 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 5 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.