ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
Which of the following lymph node groups is most commonly involved in breast cancer?
Correct Answer: D
Rationale: The correct answer is D: Central lymph node group. In breast cancer, the central lymph node group, also known as the internal mammary nodes, is commonly involved due to their proximity to the breast tissue. These nodes receive lymphatic drainage from the breast and are often the first site of metastasis. Lateral (A), Subscapular (B), and Pectoral (C) lymph nodes are less commonly involved in breast cancer metastasis compared to the central lymph nodes. Therefore, the central lymph node group is the most likely site of lymph node involvement in breast cancer.
Question 2 of 5
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.
Correct Answer: C
Rationale: The correct answer is C: Recall; after a 30-minute delay. In the Four Unrelated Words Test, the individual is asked to recall four unrelated words after a brief delay. A 30-minute delay is crucial as it tests the individual's ability to retain and retrieve information from their long-term memory. If the individual struggles with this task, it may indicate potential memory impairment or cognitive decline. Choices A and B are incorrect as the test focuses on recall, not invention, and the time frame is typically longer than 5 minutes or 30 seconds. Choice D is incorrect as a 60-minute delay is too long for this specific test.
Question 3 of 5
In using verbal responses to assist the patient's narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective. An example of a verbal response that focuses on the health care provider's perspective would be:
Correct Answer: D
Rationale: The correct answer is D: Confrontation. Confrontation is a verbal response that focuses on the health care provider's perspective by directly addressing discrepancies or inconsistencies in the patient's narrative. This technique helps challenge the patient's denial or resistance to change, promoting self-awareness and insight. In contrast, empathy (choice A) involves understanding and sharing the patient's feelings, reflection (choice B) involves restating or paraphrasing the patient's words, and facilitation (choice C) involves encouraging the patient to continue expressing their thoughts. These responses all focus on the patient's frame of reference, rather than challenging or addressing the provider's perspective.
Question 4 of 5
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. Bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child indicate normal resonance due to increased air content in the lungs. This finding is consistent with normal lung sounds in children of this age. Palpating for pain or tenderness (choice A) is not indicated as the percussion findings are normal. Asking the child to take shallow breaths (choice B) would not change the percussion findings. Immediate referral (choice C) is unnecessary as the percussion findings are within the normal range for a child of this age.
Question 5 of 5
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Correct Answer: B
Rationale: The correct answer is B because giving feedback and reassurance during the examination is appropriate for a 4-year-old child. This approach helps to build trust, reduce anxiety, and make the child feel more comfortable. Providing reassurance also helps the child understand what is happening and promotes cooperation during the examination. Explanation for other choices: A: Explaining procedures in detail may overwhelm and increase anxiety in a 4-year-old child. C: Avoiding asking the child to remove clothing may hinder a thorough examination and compromise the child's health. D: Performing a head-to-toe examination starting with the ears may not be developmentally appropriate or engaging for a 4-year-old child.