ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary consolidation. Bronchophony is a finding in which spoken words are heard distinctly and clearly through the stethoscope, indicating increased lung density. This is commonly seen in pulmonary consolidation, where air-filled lung tissue becomes filled with fluid or solid material. This can be caused by conditions such as pneumonia or lung tumors. Assessing for signs of pulmonary consolidation, such as increased tactile fremitus, dullness to percussion, and crackles on auscultation, is crucial. Choices A, B, and D are incorrect because bronchophony is not typically associated with these conditions. Airway obstruction, emphysema, and asthma have different characteristic auscultation findings and are not directly linked to bronchophony.
Question 2 of 5
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?
Correct Answer: C
Rationale: The correct answer is C because BSE (Breast Self-Examination) on a monthly basis helps women become familiar with their breasts, enabling them to detect any abnormal changes early. This empowers women to seek timely medical help if needed, potentially improving outcomes. Choice A is incorrect as having children does not determine the importance of BSE. Choice B is incorrect as the statistic of one in nine women developing breast cancer does not directly relate to the importance of BSE. Choice D is incorrect because while BSE can help in early detection, it is not a guaranteed life-saving measure between mammograms.
Question 3 of 5
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?
Correct Answer: C
Rationale: The correct answer is C: No further response is needed because sinus arrhythmia can occur normally. Sinus arrhythmia is a common finding in young individuals, characterized by a variation in heart rate with respiration. In this case, the irregular rhythm of the apical pulse with speeding up on inspiration and slowing on expiration is consistent with sinus arrhythmia. It is a benign condition and does not require further intervention. Options A and D are incorrect as they are unnecessary and may cause unnecessary worry for the patient. Option B is also unnecessary at this point as the irregular rhythm is likely due to sinus arrhythmia and does not require immediate ECG confirmation.
Question 4 of 5
A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be?
Correct Answer: D
Rationale: The correct answer is D: Epidermoid cysts. Epidermoid cysts are common benign cysts that can occur on the scrotum. In this case, the description of firm, nontender yellow nodules on the scrotum fits with the presentation of epidermoid cysts. The patient's history of gradual growth and lack of associated symptoms such as pain or systemic symptoms also support this diagnosis. Condylomata acuminata (choice A) are genital warts caused by HPV and typically present as soft, pink, or grayish growths. Syphilitic chancre (choice B) is a painless ulcer caused by syphilis, which would not present as yellow nodules. Peyronie's disease (choice C) involves curvature of the penis and is not related to scrotal nodules. Therefore, based on the presentation and characteristics of the lesions, epidermoid cysts are the most likely diagnosis.
Question 5 of 5
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Presence of palpable lymph nodes. In children, lymph nodes are more superficial and easily palpable due to their higher metabolic rate and active immune system. This is a normal finding in healthy children. Excessive swelling of lymph nodes (A) would indicate an abnormal response to infection. The absence of palpable nodes (C) is not expected as even in young children, lymph nodes are palpable. Having fewer and smaller lymph nodes (D) is not typical in healthy children and would be concerning for an underlying issue.