ATI RN
Neurological Vital Signs Assessment Questions
Question 1 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 2 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 3 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.
Question 4 of 5
During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel 'heavy in the calf' and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
Correct Answer: B
Rationale: The correct answer is B: Varicose veins. The woman's symptoms of heavy legs, foot cramps, and dilated, tortuous veins in the lower legs are classic signs of varicose veins. Varicose veins occur due to weakened valves in the veins, leading to pooling of blood and vein enlargement. Deep-vein thrombophlebitis (choice A) presents with redness, warmth, and swelling in the affected limb, which are not mentioned. Lymphedema (choice C) is characterized by persistent swelling, typically in one limb, due to lymphatic system dysfunction, not dilated veins. Raynaud phenomenon (choice D) involves episodes of reduced blood flow to extremities, causing color changes and numbness, which are not indicated in this scenario.
Question 5 of 5
A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
Correct Answer: B
Rationale: Step 1: Calculate BMI: BMI = weight (kg) / height (m)^2 BMI = 19.5 kg / (1.65 m)^2 BMI = 19.5 kg / 2.72 m^2 BMI = 7.17 Step 2: Interpretation of BMI: BMI of 19.5 falls within the normal range (18.5-24.9) for a 15-year-old. Step 3: Rationale for Correct Answer (B): The correct answer is to reassure the mother that her daughter's BMI of 19.5 is normal for her age. There are no indicators of anorexia or obesity based on the BMI calculation. Step 4: Summary of Incorrect Choices: A: Referring to a nutritionist and psychologist for anorexia is incorrect as the BMI is within the normal range. C: Providing exercise information for obesity is incorrect as the BMI does not indicate obesity. D: