ATI RN
Vital Signs Assessment Questions
Question 1 of 5
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
Correct Answer: C
Rationale: Correct Answer: C. Allergic rhinitis Rationale: The patient's symptoms of itching, sneezing, and clear rhinorrhea are classic signs of allergic rhinitis. The pale and swollen turbinates also support this diagnosis, as they are common findings in allergic rhinitis due to inflammation from allergens. Incorrect Choices: A: Nasal polyps - Nasal polyps typically present with nasal congestion, loss of smell, and may be associated with asthma. They are not commonly associated with clear rhinorrhea and itching. B: Acute sinusitis - Acute sinusitis is characterized by facial pain, pressure, purulent nasal discharge, and fever. The absence of these symptoms makes acute sinusitis less likely. D: Acute rhinitis - Acute rhinitis, or the common cold, usually presents with thick nasal discharge, sore throat, and low-grade fever. The clear rhinorrhea and itching in this patient are more
Question 2 of 5
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
Correct Answer: B
Rationale: The correct answer is B: The location of most breast tumors. This is because statistically, the upper outer quadrant of the breast is where the majority of breast tumors are found. This area is more glandular and has more breast tissue, making it a common site for tumors to develop. It is important to focus on this area during a breast examination to detect any abnormalities early. A: The largest quadrant of the breast - This is not the reason why examining the upper outer quadrant is important for detecting breast tumors. C: Where most of the suspensory ligaments attach - While true, this is not the primary reason for focusing on the upper outer quadrant during a breast examination. D: More prone to injury and calcifications than other locations in the breast - While calcifications can occur in this area, it is not the primary reason for its importance in detecting breast tumors.
Question 3 of 5
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Asymmetry of breast size is not uncommon, as breasts are typically not perfectly symmetrical. 2. The nurse should verify that the change is not new to rule out any concerning underlying issues. 3. This step is important to ensure the asymmetry is not a new development, which could indicate a potential problem. 4. By verifying that the change is not new, the nurse can provide appropriate care or further evaluation if needed. Summary of why the other choices are incorrect: A: Breasts do not need to always be symmetric; natural variation exists. B: Breastfeeding can cause temporary asymmetry, but the nurse should still verify the change is not new. D: Asymmetry is not necessarily indicative of inflammation or growth; verifying the change's timeline is crucial.
Question 4 of 5
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. 'I'll be sleeping great, and then I wake up and feel like I can't get my breath.' The nurse's best response to this would be:
Correct Answer: C
Rationale: The correct answer is C: 'Do you have any history of problems with your heart?' Rationale: 1. Difficulty sleeping and waking up feeling breathless can be indicative of cardiac issues like heart failure or arrhythmias. 2. Asking about a history of heart problems is crucial to assess the patient's risk factors and determine the need for further cardiac evaluation. 3. This response shows the nurse's understanding of the potential seriousness of the symptoms and the need to investigate cardiac health. Summary: - Option A (Electrocardiogram) is not the best initial response as it jumps to a specific test without gathering more information. - Option B (Hot at night) dismisses the symptoms without considering underlying health issues. - Option D (Sinus or respiratory infection) does not address the potential cardiac cause of the symptoms.
Question 5 of 5
A 28-year-old musician comes to your clinic, complaining of a 'spot' on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed. His mother has rheumatoid arthritis and he doesn't know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely the diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Syphilitic chancre. The key features supporting this diagnosis are a painless, indurated ulcer on the penis with no associated symptoms like burning urination or pain during intercourse. The presence of nontender lymphadenopathy in the inguinal region is also suggestive of syphilis. The risk factors of multiple sexual partners, previous history of nongonococcal urethritis, and IV drug use increase the likelihood of a sexually transmitted infection like syphilis. Condylomata acuminata (choice A) presents as warty growths, not ulcers. Genital herpes (choice B) typically presents with painful vesicles or ulcers. Penile carcinoma (choice D) usually presents with changes in the skin texture or color, not a single ulcer. Therefore, the most likely diagnosis based on the presentation and risk factors is syphilitic chancre.