ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
Correct Answer: C
Rationale: Rationale: Acromegaly is a condition caused by excessive growth hormone production, leading to overgrowth of bones in the face, head, hands, and feet. This results in characteristic features such as enlarged facial bones, hands, and feet. The correct answer is C because it aligns with the typical assessment findings in acromegaly. Summary of other choices: A (Heavy, flattened facial features): This is not consistent with acromegaly, as the condition is characterized by overgrowth of bone rather than flattened features. B (Growth retardation and a delayed onset of puberty): These findings are more indicative of growth hormone deficiency rather than excess, which is seen in acromegaly. D (Increased height and weight and delayed sexual development): While increased height and weight may occur, delayed sexual development is not a common feature of acromegaly.
Question 2 of 5
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:
Correct Answer: A
Rationale: The correct answer is A: Tinea capitis. Tinea capitis is a fungal infection of the scalp that often presents with hair loss, scaling, and broken hair in patches. In this case, the patient's symptoms of hair loss, patchy scaling, and broken hair are consistent with tinea capitis. The nurse should suspect this diagnosis based on the clinical presentation. Other choices are incorrect because: B: Folliculitis typically presents with inflamed hair follicles, pustules, and redness. It is not characterized by patchy hair loss and scaling. C: Toxic alopecia is hair loss due to exposure to toxins or chemicals, which is not suggested by the symptoms described. D: Seborrheic dermatitis presents with greasy, yellowish scaling on the scalp, but typically does not cause patchy hair loss as described in the case.
Question 3 of 5
During an interview, the patient states he has the sensation that 'everything around him is spinning.' The nurse recognizes that the portion of the ear responsible for this sensation is the:
Correct Answer: D
Rationale: The correct answer is D: Labyrinth. The labyrinth is a structure in the inner ear that contains the vestibular system responsible for balance and spatial orientation. The sensation of spinning or vertigo is related to disturbances in the labyrinth. CN VIII, the vestibulocochlear nerve, carries information from the labyrinth to the brain. The cochlea (A) is responsible for hearing, not balance. The Organ of Corti (C) is a structure within the cochlea involved in hearing, not balance. Therefore, the correct choice is D as it directly relates to the sensation of spinning experienced by the patient.
Question 4 of 5
The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:
Correct Answer: C
Rationale: The correct answer is C because the presence of a crusty nodule that intermittently bleeds, does not heal, and has an ulcerated crusted appearance with an indurated base raises suspicion for potential carcinoma. This presentation is concerning for skin cancer, specifically a squamous cell carcinoma or basal cell carcinoma. Therefore, the patient should be referred for a biopsy to confirm the diagnosis and initiate appropriate treatment. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a painless, mobile, smooth nodule, a keloid (B) is characterized by an overgrowth of scar tissue and is not associated with the described symptoms, and a tophus (D) is a deposit of uric acid crystals seen in gout, which would present differently than the described ulcerated crusted nodule.
Question 5 of 5
A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection?
Correct Answer: C
Rationale: The correct answer is C because tonsils that are 3+/1-4+ with large white spots are indicative of exudative tonsillitis, which commonly occurs in acute bacterial infections like streptococcal pharyngitis. Here's the rationale: 1. Tonsils 3+ indicate significant enlargement, more than the normal size. 2. 1-4+ refers to the extent of the white spots or exudate present on the tonsils. 3. Large white spots suggest a substantial amount of exudate, commonly seen in bacterial infections like streptococcal pharyngitis. Therefore, the presentation of enlarged tonsils with large white spots aligns with an acute bacterial infection. Other choices are incorrect: A: Tonsils are not significantly enlarged nor do they have white spots. B: While there is white debris, it is not extensive as indicated by the 1-4+ scale. D: Pale coloring does not indicate an