ATI RN
Assessing Vital Signs Questions
Question 1 of 5
The primary muscles of respiration include the:
Correct Answer: A
Rationale: The diaphragm and intercostal muscles are the primary muscles of respiration. The diaphragm contracts during inhalation, increasing the volume of the thoracic cavity, while the intercostal muscles assist in expanding the ribcage. This creates negative pressure in the lungs, allowing air to flow in. The other choices, sternomastoids and scaleni, trapezii and rectus abdominis, and external obliques and pectoralis major, are not directly involved in the inhalation and exhalation process of respiration, making them incorrect choices.
Question 2 of 5
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:
Correct Answer: B
Rationale: Rationale: Option B is correct because the nurse should gather more information to assess the patient's pain properly. This response shows active listening and empathy, facilitating a comprehensive evaluation. Option A is incorrect as it dismisses the patient's concern and provides inaccurate information about breast cancer. Option C is incorrect as it shifts the focus to the nurse's experience rather than addressing the patient's current situation. Option D is incorrect because while breast pain can be benign, assuming it is always benign without further assessment can lead to missed diagnoses.
Question 3 of 5
Which of these statements describes the closure of the valves in a normal cardiac cycle?
Correct Answer: C
Rationale: The correct answer is C because in a normal cardiac cycle, the closure of the valves follows a specific sequence. The mitral valve closes slightly before the tricuspid valve due to the ventricular pressure changes. The closure of the mitral valve marks the beginning of systole, while the tricuspid valve closes shortly after. Choices A and B are incorrect as they do not accurately describe the sequence of valve closure. Choice D is incorrect because the tricuspid and pulmonic valves do not close at the same time in a normal cardiac cycle.
Question 4 of 5
During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
Correct Answer: C
Rationale: The correct answer is C: Displacement of the heart from elevation of the diaphragm. During pregnancy, the growing uterus pushes the diaphragm upwards, causing the heart to be displaced upwards and laterally. This displacement results in the apical impulse being palpated at a higher position, such as the fourth left intercostal space lateral to the midclavicular line. This finding is a normal physiological change due to pregnancy and does not indicate any cardiac pathology. Explanation of other choices: A: Right ventricular hypertrophy - This is unlikely in a pregnant patient without underlying cardiac conditions. B: Increased volume and size of the heart as a result of pregnancy - While the heart may undergo some changes during pregnancy, palpating the apical impulse at a higher position is specifically due to displacement of the heart by the elevated diaphragm, not increased heart size. D: Increased blood flow through the internal mammary artery - This choice is unrelated to the displacement of the heart and the
Question 5 of 5
A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a 'bag of worms' in the left scrotum, superior to the testicles. Which of the following is most likely?
Correct Answer: B
Rationale: The correct answer is B: Varicocele. Varicocele is characterized by dilated and tortuous veins within the spermatic cord, giving a 'bag of worms' sensation. It typically occurs on the left side and is more common in young men. Rationale: 1. Hydrocele of the spermatic cord (A) presents as a fluid-filled sac around the spermatic cord, not as dilated veins. 2. Testicular carcinoma (C) typically presents as a painless lump within the testicle, not as dilated veins in the spermatic cord. 3. A normal vas deferens (D) is a normal part of the male reproductive anatomy and would not present as a 'bag of worms' sensation. In summary, the presence of dilated and tortuous veins in the left scrotum, superior to the testicles, is most indicative of a varicocele, making it the correct choice.