ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
Correct Answer: B
Rationale: The correct answer is B: Ipsilateral axillary. When a patient reports a breast infection, it is likely localized to one breast. The lymphatic drainage from the breast primarily flows to the ipsilateral axillary lymph nodes. Therefore, the nurse should expect to find enlargement in the ipsilateral axillary nodes as they are the first line of defense in filtering out any infection or inflammation from the affected breast. Choices A, C, and D are incorrect because nonspecific node enlargement would not be specific to a breast infection, contralateral axillary nodes would not be affected by a unilateral breast infection, and inguinal and cervical nodes are not typically involved in breast infections.
Question 2 of 5
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
Correct Answer: D
Rationale: The correct answer is D: Presence of dyspnea or diaphoresis when sucking. This information is crucial as it could indicate a medical issue such as a respiratory problem or heart condition affecting the baby's ability to feed properly, leading to poor weight gain. Dyspnea (difficulty breathing) and diaphoresis (excessive sweating) during sucking are red flags that require immediate medical attention. A: The infant's sleeping position is important for preventing Sudden Infant Death Syndrome (SIDS) but not directly related to the feeding issue. B: Sibling history of eating disorders may not be relevant to the current infant's feeding difficulties. C: Amount of background noise when eating is unlikely to be the primary factor affecting the infant's weight gain issue.
Question 3 of 5
A 29-year-old married computer programmer comes to your clinic, complaining of 'something strange' going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Scrotal hernia. The patient's presentation of a long-standing lump in the left testis, aching in the left testis, and a palpable mass in the left scrotum that cannot be pushed back through the inguinal ring suggests a scrotal hernia. The inability to palpate above the mass through the left inguinal ring indicates a hernia that has descended into the scrotum. Other choices are incorrect because a hydrocele presents as a painless scrotal swelling, scrotal edema would typically be bilateral and associated with systemic conditions, and varicocele is a benign condition that feels like a bag of worms and is more common on the left side.
Question 4 of 5
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
Correct Answer: A
Rationale: The correct answer is A. Intraluminal valves ensure unidirectional flow toward the heart. These valves prevent backflow and promote blood flow towards the heart. Skeletal muscle contractions (choice B) help propel blood towards the heart, but they do not ensure unidirectional flow. The heart is not a high-pressure system (choice C), and venous return relies more on mechanisms outside the heart. Choice D incorrectly suggests that thoracic and abdominal pressure changes facilitate venous return, but the primary mechanism is the presence of one-way valves in veins.
Question 5 of 5
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:
Correct Answer: A
Rationale: The correct answer is A. Nonpitting, hard edema is commonly associated with lymphatic obstruction. Lymphatic obstruction prevents the drainage of interstitial fluid, leading to accumulation and the characteristic nonpitting, hard edema. In this case, the presence of edema in only the left lower leg and ankle suggests localized lymphatic obstruction. Choice B is incorrect because alterations in arterial function typically result in arterial insufficiency and not edema. Choice C is incorrect because phlebitis of a superficial vein usually causes unilateral edema rather than bilateral edema. Choice D is incorrect as long-standing arterial obstruction typically leads to tissue ischemia rather than pitting edema.