ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?
Correct Answer: C
Rationale: The correct answer is C because BSE (Breast Self-Examination) on a monthly basis helps women become familiar with their breasts, enabling them to detect any abnormal changes early. This empowers women to seek timely medical help if needed, potentially improving outcomes. Choice A is incorrect as having children does not determine the importance of BSE. Choice B is incorrect as the statistic of one in nine women developing breast cancer does not directly relate to the importance of BSE. Choice D is incorrect because while BSE can help in early detection, it is not a guaranteed life-saving measure between mammograms.
Question 2 of 5
A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be?
Correct Answer: D
Rationale: The correct answer is D: Epidermoid cysts. Epidermoid cysts are common benign cysts that can occur on the scrotum. In this case, the description of firm, nontender yellow nodules on the scrotum fits with the presentation of epidermoid cysts. The patient's history of gradual growth and lack of associated symptoms such as pain or systemic symptoms also support this diagnosis. Condylomata acuminata (choice A) are genital warts caused by HPV and typically present as soft, pink, or grayish growths. Syphilitic chancre (choice B) is a painless ulcer caused by syphilis, which would not present as yellow nodules. Peyronie's disease (choice C) involves curvature of the penis and is not related to scrotal nodules. Therefore, based on the presentation and characteristics of the lesions, epidermoid cysts are the most likely diagnosis.
Question 3 of 5
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Presence of palpable lymph nodes. In children, lymph nodes are more superficial and easily palpable due to their higher metabolic rate and active immune system. This is a normal finding in healthy children. Excessive swelling of lymph nodes (A) would indicate an abnormal response to infection. The absence of palpable nodes (C) is not expected as even in young children, lymph nodes are palpable. Having fewer and smaller lymph nodes (D) is not typical in healthy children and would be concerning for an underlying issue.
Question 4 of 5
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?
Correct Answer: C
Rationale: The correct answer is C: Swishing, whooshing sound. This sound indicates venous flow in Doppler ultrasonic stethoscope. Venous flow produces a continuous, swishing sound due to the irregularity of blood flow in veins. Option A, a low humming sound, does not accurately represent venous flow. Option B, a regular 'lub, dub' pattern, is typical of normal heart sounds. Option D, a steady, even, flowing sound, does not reflect the nature of venous flow, which is more turbulent and irregular.
Question 5 of 5
A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing?
Correct Answer: C
Rationale: The correct answer is C: Rapid and deep breathing. In diabetic ketoacidosis, the body compensates for metabolic acidosis by increasing the respiratory rate (rapid) and depth (deep) in an effort to blow off excess carbon dioxide and decrease blood acidity. This is known as Kussmaul breathing. Option A is incorrect because normal breathing would not be expected in a state of metabolic acidosis. Option B is incorrect as rapid and shallow breathing is not typically seen in diabetic ketoacidosis. Option D is incorrect as slow breathing is not a characteristic of compensatory mechanisms in diabetic ketoacidosis.