ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
Correct Answer: B
Rationale: The correct answer is B: Firm pressure. When palpating sinus areas, normal findings should elicit a sensation of firm pressure. This is because the sinuses are air-filled cavities that should not cause pain or discomfort when palpated. Sensing firm pressure indicates normal sinus function. Choices A, C, and D are incorrect because normal sinus palpation should not result in no sensation, pain during palpation, or pain sensation behind the eyes. These sensations could indicate sinus inflammation, infection, or other abnormalities that should be further assessed.
Question 2 of 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
Correct Answer: B
Rationale: The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management. Incorrect choices: A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold. C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent. D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.
Question 3 of 5
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? Tell the mother that:
Correct Answer: C
Rationale: The correct answer is C because unilateral breast enlargement with tenderness in a 10-year-old girl is most likely due to normal breast development, known as thelarche. The nurse should reassure the mother that it is common for breast development to be asymmetric initially and that an examination can confirm this. This response is appropriate because breast cancer is extremely rare in preadolescent girls, making option B incorrect. Option A is incorrect as immediate examination is not necessary unless there are other concerning symptoms. Option D is incorrect as breast tenderness can occur during breast development due to hormonal changes. Thus, option C is the best response based on the presentation and age of the patient.
Question 4 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 5 of 5
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
Correct Answer: B
Rationale: The correct answer is B: Blood flow turbulence. The blowing, swishing sound heard over the left carotid artery indicates a bruit, which is caused by turbulent blood flow. This can be due to atherosclerosis or stenosis in the carotid artery. Increased cardiac output (A) would not manifest as a bruit. Fluid volume overload (C) would not cause a bruit specifically over the carotid artery. Ventricular hypertrophy (D) is unrelated to the presence of a bruit. In summary, the presence of a bruit indicates blood flow turbulence, typically due to underlying vascular pathology.