ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Correct Answer: A
Rationale: Rationale: Position A (Supine with the arms raised over her head) is most likely to make significant lumps more distinct during breast palpation because raising the arms stretches the breast tissue, making abnormalities easier to feel. This position allows for better access to all areas of the breast. In contrast, choices B (Sitting with the arms relaxed at her sides) and C (Supine with the arms relaxed at her sides) do not provide the same level of breast tissue stretching, making it harder to detect lumps. Choice D (Sitting with the arms flexed and fingertips touching her shoulders) may limit the nurse's ability to fully palpate the breast due to the arms being in the way.
Question 2 of 5
A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Scrotal edema. The patient's presentation of a swollen scrotum that worsens with standing and improves with lying down is consistent with scrotal edema, which is often associated with fluid accumulation due to conditions like heart failure, renal failure, or liver disease. The patient's history of high blood pressure, coronary artery disease, and shortness of breath with exertion suggest possible heart failure as the underlying cause. The absence of bulges with bearing down rules out a scrotal hernia. Hydrocele presents as a painless collection of fluid around the testicle, typically without systemic symptoms. Varicocele is a dilatation of the veins in the scrotum, usually described as a "bag of worms" sensation, and is not typically associated with the patient's symptoms.
Question 3 of 5
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, 'What happens to my circulation when this vein is removed?' The nurse should reply:
Correct Answer: D
Rationale: Rationale for Correct Answer D: 1. The great saphenous vein is a superficial vein and removal doesn't significantly impact circulation. 2. Deeper veins, like the femoral and popliteal veins, are responsible for major venous return. 3. These deeper veins will compensate for the removal of the great saphenous vein, maintaining circulation. 4. Therefore, removing the great saphenous vein won't harm circulation due to the presence of deeper veins. Summary of Incorrect Choices: A: Incorrect. Venous insufficiency isn't a common problem post-surgery as other veins compensate. B: Incorrect. Dismissing the significance of vein removal and its impact on circulation is inaccurate. C: Incorrect. While there may be decreased circulation in the superficial system, deep venous return is preserved.
Question 4 of 5
During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:
Correct Answer: B
Rationale: The correct answer is B: Venous filling within 15 seconds. When the patient is sitting up after having his legs elevated, venous blood should quickly return to the legs due to gravity, resulting in venous filling within about 15 seconds. This is a normal physiological response. A: Significant elevational pallor is incorrect as pallor would indicate poor circulation, which is not expected in this scenario. C: No change in the coloration of the skin is incorrect as there should be a change in color due to venous filling. D: Color returning to the feet within 20 seconds of assuming a sitting position is not as specific as option B, which mentions venous filling specifically within 15 seconds.
Question 5 of 5
A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient?
Correct Answer: D
Rationale: The correct answer is D. Asking the patient to describe what happened provides crucial information about the onset, possible cause, and nature of the knee pain. This helps in understanding the context and determining the appropriate follow-up questions or examinations. Option A focuses solely on pain intensity, neglecting important context. Option B assumes a past injury without gathering current information. Option C asks for a specific timeframe without capturing the full picture of the pain episode.