ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
Correct Answer: B
Rationale: Step-by-step rationale for choice B (Decreased mobility of the thorax) as the correct answer: 1. With aging, the rib cage becomes less flexible, leading to decreased thoracic mobility. 2. This decrease in thoracic mobility is a normal finding in older adults due to changes in the musculoskeletal system. 3. Assessing for decreased thoracic mobility is important as it can impact respiratory function and overall health. Summary: A: Increased thoracic expansion is not a normal finding in older adults as aging typically results in decreased flexibility. C: Decreased anteroposterior diameter may occur in certain conditions but is not a consistent normal finding in older adults. D: Bronchovesicular breath sounds throughout the lungs are not specific to assessing the respiratory system in older adults.
Question 2 of 5
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
Correct Answer: D
Rationale: The correct answer is D. When a woman slowly lifts her arms above her head during a breast examination, it allows for better visualization and detection of any nipple or skin retraction. This position stretches the breast tissue and skin, making any abnormalities more apparent. Additionally, observing for any lag or retraction in movement while the arms are raised can help identify any potential issues. Choice A is incorrect because bending over and touching her toes does not provide the necessary positioning to properly assess for nipple and skin retraction. Choice B is incorrect because lying down on the left side may not provide the same level of stretching and visibility as lifting the arms above the head. Choice C is incorrect because shifting from a supine position to a standing position may not provide the optimal angle for assessing nipple and skin retraction.
Question 3 of 5
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:
Correct Answer: B
Rationale: The correct answer is B. Listening with the bell of the stethoscope allows the nurse to assess for bruits, abnormal sounds indicating turbulent blood flow in carotid arteries, which could indicate potential blockages or narrowing. Palpating the artery in the upper one third of the neck (A) is not recommended as it could potentially dislodge plaque and cause a stroke. Simultaneously palpating both arteries (C) is not necessary for this assessment. Instructing the patient to take slow deep breaths (D) is not relevant to assessing the carotid arteries for bruits.
Question 4 of 5
A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable. What abnormality of the scrotum does he most likely have?
Correct Answer: D
Rationale: The correct answer is D: Varicocele. Varicocele is the most likely abnormality in this case due to the presence of a "bag of worms" feeling upon palpation through the right inguinal ring, especially when the patient bears down. Varicocele is a dilation of the veins within the spermatic cord, leading to a mass resembling a bag of worms. The patient's symptoms of aching in the testicle that worsens throughout the day and improves in the morning are characteristic of varicocele, as increased intra-abdominal pressure exacerbates the symptoms. The absence of discrete masses on palpation and no bulges on bearing down help rule out other conditions like scrotal hernia. Hydrocele presents as a painless fluid-filled sac around the testicle, not a "bag of worms." Scrotal edema would present with swelling and pitting edema, which are not described in this case.
Question 5 of 5
Which vein(s) is(are) responsible for most of the venous return in the arm?
Correct Answer: D
Rationale: The correct answer is D: Superficial. The superficial veins, like the basilic and cephalic veins, are responsible for most of the venous return in the arm due to their larger size and proximity to the surface. These veins run parallel to major arteries, assisting in venous return through the pumping action of nearby muscles. Deep veins are important but less significant in venous return compared to superficial veins in the arm. Ulnar and subclavian veins are not primarily responsible for venous return in the arm.