ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The nurse is auscultating the chest in an adult. Which technique is correct?
Correct Answer: C
Rationale: The correct technique for auscultating the chest in an adult is to firmly hold the diaphragm of the stethoscope against the chest. This allows for optimal transmission of sound and better detection of abnormal lung or heart sounds. Instructing the patient to take deep, rapid breaths (Choice A) may interfere with accurate auscultation. Breathing through the nose (Choice B) does not impact the technique. Lightly holding the bell of the stethoscope (Choice D) may lead to poor sound transmission and decreased sensitivity in detecting faint sounds.
Question 2 of 5
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Asymmetry of breast size is not uncommon, as breasts are typically not perfectly symmetrical. 2. The nurse should verify that the change is not new to rule out any concerning underlying issues. 3. This step is important to ensure the asymmetry is not a new development, which could indicate a potential problem. 4. By verifying that the change is not new, the nurse can provide appropriate care or further evaluation if needed. Summary of why the other choices are incorrect: A: Breasts do not need to always be symmetric; natural variation exists. B: Breastfeeding can cause temporary asymmetry, but the nurse should still verify the change is not new. D: Asymmetry is not necessarily indicative of inflammation or growth; verifying the change's timeline is crucial.
Question 3 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 4 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 5 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.