ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
Correct Answer: C
Rationale: The correct answer is C because bronchovesicular breath sounds in the peripheral lung fields are an expected finding in a 4-year-old child. This is due to the normal anatomy and physiology of a child's respiratory system at that age. Bronchovesicular breath sounds are commonly heard in children and are a combination of bronchial and vesicular sounds. These sounds are normal in children up to the age of 5 and are typically heard in the peripheral lung fields. Choice A is incorrect because crepitus palpated at the costochondral junctions is not an expected finding in a 4-year-old child's respiratory assessment. Crepitus may indicate air or gas under the skin and is not a normal finding in a respiratory assessment. Choice B is incorrect because no diaphragmatic excursion due to decreased inspiratory volume is not a typical finding in a 4-year-old child. Children of this age should have adequate diaphragmatic excursion, and a lack of it may indicate respiratory
Question 2 of 5
Which of these clinical situations would the nurse consider to be outside normal limits?
Correct Answer: D
Rationale: The correct answer is D because the presence of thick yellow discharge from both nipples in a patient who has had two pregnancies and breastfed her children is outside the normal limits. This could indicate a condition such as galactorrhea, which is abnormal lactation unrelated to breastfeeding. The discharge may be due to hormonal imbalances or other underlying issues that require further investigation. Explanation for other choices: A: Soft and slightly sagging breasts in a patient entering menopause can be considered within normal limits due to hormonal changes. B: Firm, transverse ridges along the lower quadrant of breasts in a patient who has never been pregnant may indicate fibrocystic changes, which are common and typically not concerning. C: Nodular and engorged breast tissue with slight pain before menstruation is a common premenstrual symptom and is usually within normal limits.
Question 3 of 5
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
Correct Answer: D
Rationale: The forceful movement along the sternal border indicates right ventricular enlargement. This is because the right ventricle is located close to the sternum. Enlargement of the left ventricle (Choice C) typically causes a sustained apical impulse. A systolic murmur (Choice B) is usually heard during auscultation, not observed visually. A normal heart (Choice A) would not exhibit forceful movement along the sternal border. Therefore, the correct answer is D.
Question 4 of 5
A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have?
Correct Answer: A
Rationale: The correct answer is A: Hydrocele. A hydrocele is a fluid-filled sac surrounding the testicle that typically presents as a painless mass in the scrotum. In this case, the patient's presentation of a painless, soft, cystic-like lesion over the right testicle is consistent with a hydrocele. The absence of other concerning symptoms like weight loss, fever, or night sweats also points towards a benign condition like hydrocele. The lack of difficulty with inguinal ring passage and absence of bulges with weight bearing rule out a scrotal hernia. Testicular tumor typically presents with different characteristics such as testicular pain or hard, irregular masses. Varicocele is characterized by enlarged veins in the scrotum, not a fluid-filled sac. Therefore, based on the patient's presentation and physical examination findings, the most likely diagnosis is a hydrocele.
Question 5 of 5
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
Correct Answer: B
Rationale: The correct answer is B because prolonged bed rest can lead to decreased muscle contraction in the legs, slowing blood flow and increasing the risk of venous stasis and clot formation. This increases the risk of developing venous disease. A: Pregnancy increases pressure on veins but typically resolves postpartum. C: Smoking is a risk factor for arterial disease, not venous disease. D: Anticoagulants are used to prevent clot formation, reducing the risk of venous disease. In summary, choice B is correct because prolonged bed rest directly contributes to venous stasis and clot formation, making it the highest risk factor among the options provided.