ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:
Correct Answer: C
Rationale: The correct answer is C because the presence of a crusty nodule that intermittently bleeds, does not heal, and has an ulcerated crusted appearance with an indurated base raises suspicion for potential carcinoma. This presentation is concerning for skin cancer, specifically a squamous cell carcinoma or basal cell carcinoma. Therefore, the patient should be referred for a biopsy to confirm the diagnosis and initiate appropriate treatment. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a painless, mobile, smooth nodule, a keloid (B) is characterized by an overgrowth of scar tissue and is not associated with the described symptoms, and a tophus (D) is a deposit of uric acid crystals seen in gout, which would present differently than the described ulcerated crusted nodule.
Question 2 of 5
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
Correct Answer: A
Rationale: The correct answer is A: The spinous process of C7. The vertebra prominens is the most prominent vertebra at the base of the neck, which is C7. This is because the spinous process of C7 is longer and more palpable than other cervical vertebrae. Rationales for the incorrect choices: B: Usually nonpalpable in most individuals - This is incorrect as the vertebra prominens (C7) is usually palpable due to its prominent spinous process. C: Opposite the interior border of the scapula - This is incorrect as the vertebra prominens is located at the base of the neck, not opposite the scapula. D: Located next to the manubrium of the sternum - This is incorrect as the vertebra prominens is located higher up in the neck than the manubrium of the sternum.
Question 3 of 5
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
Correct Answer: B
Rationale: The correct answer is B: When part of the lung is obstructed or collapsed. Unequal chest expansion can occur when there is an obstruction or collapse of a portion of the lung, leading to decreased lung expansion on that side. This can result in one side of the chest moving less during breathing. Other options are incorrect because: A: In an obese patient - obesity may affect chest wall movement but does not directly cause unequal chest expansion. C: When bulging of the intercostal spaces is present - bulging of intercostal spaces may indicate increased work of breathing but does not necessarily lead to unequal chest expansion. D: When accessory muscles are used to augment respiratory effort - while accessory muscles may be used in respiratory distress, they do not directly cause unequal chest expansion.
Question 4 of 5
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?
Correct Answer: D
Rationale: The correct answer is D because the statement accurately describes colostrum, the first milk produced during pregnancy. Colostrum is a thick, yellow fluid that can be expressed from the breasts as early as the fourth month of pregnancy. It is rich in antibodies and nutrients essential for the newborn. A: Incorrect. Breast milk does not immediately appear after delivery; it takes a few days for mature milk to come in. B: Incorrect. Breast milk is rich in fat, not just protein and sugars. Fat is crucial for a baby's growth and development. C: Incorrect. Colostrum is a nutrient-rich fluid that provides essential nutrients to the newborn, even though it may not have the same composition as mature breast milk. In summary, choice D is correct because it accurately describes the early milk production during pregnancy, while the other choices provide inaccurate information about breast milk.
Question 5 of 5
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities. A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.