ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?
Correct Answer: D
Rationale: Rationale: In otitis externa, the infection usually involves the outer ear canal and surrounding tissues. Enlarged superficial cervical nodes are a common sign due to the lymphatic drainage in the area. Rhinorrhea (A) is associated with nasal congestion, not ear infections. Periorbital edema (B) is seen in conditions affecting the eyes or surrounding tissues. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa. Ultimately, D is the correct answer as it aligns with the typical presentation of otitis externa.
Question 2 of 5
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
Correct Answer: C
Rationale: The correct answer is C: Maxillary sinusitis. The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and pain in the cheeks and teeth on one side with palpation are indicative of maxillary sinusitis. The maxillary sinuses are located in the cheekbones, and inflammation can lead to these specific symptoms. Posterior epistaxis (A) refers to bleeding from the back of the nose, which is not consistent with the patient's symptoms. Frontal sinusitis (B) would present with symptoms in the forehead region, not in the cheeks and teeth. Nasal polyps (D) are growths in the nasal passages and usually do not cause the specific symptoms described in the case.
Question 3 of 5
When inspecting the anterior chest of an adult, the nurse should include which assessment?
Correct Answer: D
Rationale: The correct answer is D, examining the shape and configuration of the chest wall. This assessment helps identify any abnormalities such as barrel chest or pectus excavatum. Diaphragmatic excursion (A) is assessed at the posterior chest. Symmetric chest expansion (B) is relevant for assessing lung function, not specifically the anterior chest. Presence of breath sounds (C) is important but does not specifically pertain to the anterior chest assessment.
Question 4 of 5
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? The nurse should tell her that:
Correct Answer: C
Rationale: The correct answer is C because cyclic breast changes are common due to hormonal fluctuations during the monthly menstrual cycle. This is a normal physiological process where breasts may feel different at different times of the month. It is important for the nurse to reassure the woman that these changes are normal. Choice A is incorrect as it states that continual changes in breasts are unusual, which is not accurate for nonpregnant women. Choice B is incorrect as it focuses on stress as the cause of breast changes, which is not the primary reason in this case. Choice D is incorrect as it suggests that breast changes only occur during pregnancy, which is not true as hormonal fluctuations during the menstrual cycle can also cause changes in breasts.
Question 5 of 5
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:
Correct Answer: B
Rationale: The correct answer is B. Palpating the unaffected breast first allows for establishing a baseline for comparison, aiding in identifying any differences in texture, size, or tenderness. This approach helps in assessing the lump in the left breast effectively. Palpating the affected breast first (choice A) may lead to missing important comparisons. Avoiding palpation due to potential cyst rupture (choice C) is incorrect as palpation is necessary for assessment. Palpating the breast with the lump first but the axilla last (choice D) is not ideal as it doesn't prioritize establishing a baseline for accurate assessment.