ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 5
Which of the following is true regarding breast self-examination?
Correct Answer: C
Rationale: In this question about breast self-examination, option C is correct because a high proportion of breast masses are actually detected by self-examination. This is an important aspect of breast health as it empowers individuals to be proactive in their health monitoring. Option A is incorrect because the effectiveness of breast self-examination in reducing mortality from breast cancer is still debated among medical professionals. Option B is incorrect as not all organizations recommend routine breast self-exams due to varying opinions on its efficacy. Option D is also incorrect as the fear caused by finding a mass should not deter individuals from being educated on how to perform self-exams. It is crucial to provide proper education and support to overcome fears and encourage early detection. From an educational perspective, understanding the role of breast self-examination in early detection of breast masses is essential for promoting health awareness and encouraging regular self-checks. It is important to emphasize that while self-exams are not a replacement for regular screenings and clinical exams, they play a significant role in early detection and increasing individual agency in monitoring breast health.
Question 2 of 5
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, 'I buy obie get spirding and take my train.' What is the best description of this patient's problem?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Wernicke's aphasia. Wernicke's aphasia is characterized by fluent but nonsensical speech, where individuals have difficulty understanding language and may produce sentences that lack meaning or contain invented words. The patient's speech, "I buy obie get spirding and take my train," reflects this symptomatology as it lacks coherence and contains words that do not fit the context. Regarding why the other options are incorrect: - A) Global aphasia typically involves both receptive and expressive language deficits, resulting in significant impairments in both understanding and producing language. The patient in the question is producing speech, albeit nonsensical, indicating it's not a complete absence of language function. - B) Broca's aphasia is characterized by non-fluent speech, where individuals have difficulty with speech production but relatively preserved understanding. The patient's speech, although effortful, is fluent and lacks the characteristic telegraphic speech seen in Broca's aphasia. - C) Echolalia refers to the repetition of words or phrases spoken by others, which is not demonstrated in the patient's speech. Educationally, understanding different types of aphasia is crucial for healthcare providers to appropriately assess and support patients with communication impairments. Recognizing the distinct features of each type of aphasia aids in accurate diagnosis and tailored intervention strategies to improve communication and quality of life for individuals affected by stroke or other conditions impacting language processing.
Question 3 of 5
A pregnant woman states, 'I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor.' The nurse responds by stating, 'Oh, don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.' Which statement is true regarding this response? The nurse's reply was a:
Correct Answer: B
Rationale: By providing false assurance or reassurance, this courage builder relieves the woman's anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.
Question 4 of 5
The nurse is preparing to assess a hospitalized patient with significant shortness of breath. How should the nurse proceed?
Correct Answer: D
Rationale: In this scenario, option D, which is to focus on areas related to the problem and finish later, is the correct approach for the nurse to take when assessing a hospitalized patient with significant shortness of breath. This option is the most appropriate because addressing the immediate concern of shortness of breath is crucial for the patient's well-being. By focusing on areas related to the problem first, the nurse can quickly gather essential information to initiate appropriate interventions to alleviate the patient's distress. Option A, laying the patient flat for accurate cardiac and respiratory assessments, is incorrect in this case because it can worsen the patient's shortness of breath due to increased pressure on the chest and lungs. This action could further compromise the patient's respiratory status. Option B, obtaining a detailed history from a family member, is not the priority when a patient is experiencing significant shortness of breath. While obtaining a thorough history is important, addressing the immediate physiological needs of the patient takes precedence in this situation. Option C, performing a complete physical assessment immediately, is also not the best course of action because it may be overwhelming for the patient and could delay the prompt intervention needed for the shortness of breath. In an educational context, it is essential for healthcare providers to prioritize and manage acute symptoms effectively. By focusing on the problem at hand, nurses can provide timely and appropriate care to address the patient's immediate needs while still maintaining a comprehensive approach to care. This approach ensures that critical issues are addressed promptly, leading to better patient outcomes.
Question 5 of 5
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
Correct Answer: B
Rationale: The correct answer is B) Prehypertension. Prehypertension is defined as a blood pressure reading that is higher than normal but not high enough to be considered hypertension. In this case, the patient's average blood pressure reading of 126/86 mm Hg falls within the prehypertension range. Option A) Normal blood pressure is incorrect because the patient's average blood pressure reading is higher than what is considered normal (which is typically around 120/80 mm Hg). Option C) Stage 1 hypertension and Option D) Stage 2 hypertension are also incorrect because the patient's blood pressure readings do not fall within the ranges defined for these categories. Stage 1 hypertension is typically defined as readings between 130-139/80-89 mm Hg, and Stage 2 hypertension is readings above 140/90 mm Hg. Educationally, understanding blood pressure categories is crucial for healthcare professionals to accurately assess and manage patients' cardiovascular health. Monitoring blood pressure trends over time helps in identifying potential health risks and guiding appropriate interventions to prevent complications associated with hypertension. It is essential for nurses to interpret and classify blood pressure readings correctly to provide optimal patient care.