ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?
Correct Answer: A
Rationale: The correct answer is A because nipples in different planes (deviated) can indicate a potential abnormality like a breast mass or underlying breast tissue changes. This can be a sign of asymmetry or a structural issue that warrants further evaluation. Choices B, C, and D are not considered abnormal findings during the inspection phase of breast examination. Choice B is a common and normal variation in breast size, while choice C indicates stretch marks which are common and not concerning. Choice D describes a normal finding of increased vascularity during pregnancy.
Question 2 of 5
A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy. Which abnormality of the penis does this patient most likely have?
Correct Answer: A
Rationale: The correct answer is A: Condylomata acuminata. The presence of moist papules on the penile shaft and corona, absence of pain with intercourse or urination, multiple sexual partners, lack of systemic symptoms, and absence of inguinal lymphadenopathy are all consistent with condylomata acuminata, which are caused by human papillomavirus (HPV) infection. Genital herpes (B) typically presents with painful vesicles, syphilitic chancre (C) presents as a painless ulcer with associated systemic symptoms, and penile carcinoma (D) usually presents with a single firm, non-tender lesion and may have associated risk factors like smoking or HPV infection, which are not present in this case.
Question 3 of 5
A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _____ the left leg.
Correct Answer: C
Rationale: The correct answer is C: Ischemia caused by a partial blockage of an artery supplying the left leg. In this scenario, the patient experiences pain in the left calf during exercise, which is relieved by resting, suggesting intermittent claudication. This is typically caused by partial blockage of an artery, leading to reduced blood flow and oxygen supply to the muscles during exercise. Venous obstruction (A) and claudication due to venous abnormalities (B) are related to issues in the venous system, not arterial supply. Ischemia due to complete arterial blockage (D) would result in more severe and constant pain, not relieved by resting.
Question 4 of 5
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
Correct Answer: A
Rationale: The correct answer is A: 1+/0-4+. This grading scale indicates mild pitting edema. The "1+" signifies slight indentation that disappears rapidly (mild), and "0-4+" indicates the depth of the indentation, with 1+ being the lowest on the scale. This specific documentation helps accurately communicate the severity of the edema. Summary of other choices: - B: 3+/0-4+: This indicates moderate to severe pitting edema, not appropriate for mild edema. - C: 4+/0-4+: This indicates severe pitting edema, not reflective of mild edema. - D: Brawny edema: Brawny edema is non-pitting and does not apply to the scenario described.
Question 5 of 5
You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning?
Correct Answer: B
Rationale: The correct answer is B because reassuring the patient that urinary symptoms are benign and not related to cancer is not a component of adaptive questioning. Adaptive questioning involves adjusting the questioning technique based on the patient's responses to gather more information effectively. Reassurance may prematurely close the conversation or influence the patient's responses. Directed questioning (A) is a component of adaptive questioning as it helps gather information systematically. Offering multiple choices (C) helps clarify the patient's symptoms. Asking the patient to explain further (D) is also a component of adaptive questioning as it seeks detailed information to better understand the patient's experience.