ATI RN
Vital Signs Assessment Questions
Question 1 of 5
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
Correct Answer: B
Rationale: The correct answer is B: The location of most breast tumors. This is because statistically, the upper outer quadrant of the breast is where the majority of breast tumors are found. This area is more glandular and has more breast tissue, making it a common site for tumors to develop. It is important to focus on this area during a breast examination to detect any abnormalities early. A: The largest quadrant of the breast - This is not the reason why examining the upper outer quadrant is important for detecting breast tumors. C: Where most of the suspensory ligaments attach - While true, this is not the primary reason for focusing on the upper outer quadrant during a breast examination. D: More prone to injury and calcifications than other locations in the breast - While calcifications can occur in this area, it is not the primary reason for its importance in detecting breast tumors.
Question 2 of 5
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. 'I'll be sleeping great, and then I wake up and feel like I can't get my breath.' The nurse's best response to this would be:
Correct Answer: C
Rationale: The correct answer is C: 'Do you have any history of problems with your heart?' Rationale: 1. Difficulty sleeping and waking up feeling breathless can be indicative of cardiac issues like heart failure or arrhythmias. 2. Asking about a history of heart problems is crucial to assess the patient's risk factors and determine the need for further cardiac evaluation. 3. This response shows the nurse's understanding of the potential seriousness of the symptoms and the need to investigate cardiac health. Summary: - Option A (Electrocardiogram) is not the best initial response as it jumps to a specific test without gathering more information. - Option B (Hot at night) dismisses the symptoms without considering underlying health issues. - Option D (Sinus or respiratory infection) does not address the potential cardiac cause of the symptoms.
Question 3 of 5
A 28-year-old musician comes to your clinic, complaining of a 'spot' on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed. His mother has rheumatoid arthritis and he doesn't know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely the diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Syphilitic chancre. The key features supporting this diagnosis are a painless, indurated ulcer on the penis with no associated symptoms like burning urination or pain during intercourse. The presence of nontender lymphadenopathy in the inguinal region is also suggestive of syphilis. The risk factors of multiple sexual partners, previous history of nongonococcal urethritis, and IV drug use increase the likelihood of a sexually transmitted infection like syphilis. Condylomata acuminata (choice A) presents as warty growths, not ulcers. Genital herpes (choice B) typically presents with painful vesicles or ulcers. Penile carcinoma (choice D) usually presents with changes in the skin texture or color, not a single ulcer. Therefore, the most likely diagnosis based on the presentation and risk factors is syphilitic chancre.
Question 4 of 5
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
Correct Answer: D
Rationale: The correct location for palpating the dorsalis pedis artery is lateral to the extensor tendon of the great toe. This is because the dorsalis pedis artery is located on the dorsum of the foot, slightly lateral to the midline, and can be palpated just lateral to the extensor hallucis longus tendon. This location allows for accurate assessment of the pulse. Choices A, B, and C are incorrect as they do not correspond to the correct anatomical location of the dorsalis pedis artery.
Question 5 of 5
When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:
Correct Answer: D
Rationale: The correct answer is D. When a bruit is heard over the femoral arteries, it indicates turbulent blood flow, which is often a result of partial occlusion in the artery. This turbulent flow causes vibrations that can be heard as a bruit. This finding suggests that there may be a narrowing or blockage in the femoral artery, which can lead to decreased blood flow to the lower extremities. Choices A, B, and C are incorrect because bruits are not typically associated with venous disease, lymphadenopathy, or hypermetabolic states in the context of femoral artery auscultation.