ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing an assessment. Which of these findings would cause the greatest concern?
Correct Answer: D
Rationale: The correct answer is D because an ulceration on the side of the tongue with rolled edges could indicate a potential malignancy like oral cancer. This finding is concerning due to its location and characteristics, which warrant further investigation and prompt intervention. Explanation for incorrect choices: A: A painful vesicle inside the cheek for 2 days is likely a benign condition like a canker sore. B: Presence of moist, nontender Stensen's ducts is a normal finding related to salivary gland function. C: Stippled gingival margins that snugly adhere to the teeth indicate healthy gum tissue and proper attachment.
Question 2 of 5
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
Correct Answer: B
Rationale: The correct answer is B: Ipsilateral axillary. When a patient reports a breast infection, it is likely localized to one breast. The lymphatic drainage from the breast primarily flows to the ipsilateral axillary lymph nodes. Therefore, the nurse should expect to find enlargement in the ipsilateral axillary nodes as they are the first line of defense in filtering out any infection or inflammation from the affected breast. Choices A, C, and D are incorrect because nonspecific node enlargement would not be specific to a breast infection, contralateral axillary nodes would not be affected by a unilateral breast infection, and inguinal and cervical nodes are not typically involved in breast infections.
Question 3 of 5
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
Correct Answer: C
Rationale: Rationale: C is correct because determining if the inversion is a recent change is crucial to assess for potential underlying causes like breast cancer. A: Incorrect because nipple inversion can be unilateral. B: Incorrect, unilateral inversion doesn't always indicate a serious condition. D: Incorrect, nipple inversion alone warrants further investigation regardless of a palpable mass.
Question 4 of 5
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
Correct Answer: D
Rationale: The correct answer is D: Presence of dyspnea or diaphoresis when sucking. This information is crucial as it could indicate a medical issue such as a respiratory problem or heart condition affecting the baby's ability to feed properly, leading to poor weight gain. Dyspnea (difficulty breathing) and diaphoresis (excessive sweating) during sucking are red flags that require immediate medical attention. A: The infant's sleeping position is important for preventing Sudden Infant Death Syndrome (SIDS) but not directly related to the feeding issue. B: Sibling history of eating disorders may not be relevant to the current infant's feeding difficulties. C: Amount of background noise when eating is unlikely to be the primary factor affecting the infant's weight gain issue.
Question 5 of 5
A 29-year-old married computer programmer comes to your clinic, complaining of 'something strange' going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Scrotal hernia. The patient's presentation of a long-standing lump in the left testis, aching in the left testis, and a palpable mass in the left scrotum that cannot be pushed back through the inguinal ring suggests a scrotal hernia. The inability to palpate above the mass through the left inguinal ring indicates a hernia that has descended into the scrotum. Other choices are incorrect because a hydrocele presents as a painless scrotal swelling, scrotal edema would typically be bilateral and associated with systemic conditions, and varicocele is a benign condition that feels like a bag of worms and is more common on the left side.