ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
Correct Answer: A
Rationale: The correct answer is A: The spinous process of C7. The vertebra prominens is the most prominent vertebra at the base of the neck, which is C7. This is because the spinous process of C7 is longer and more palpable than other cervical vertebrae. Rationales for the incorrect choices: B: Usually nonpalpable in most individuals - This is incorrect as the vertebra prominens (C7) is usually palpable due to its prominent spinous process. C: Opposite the interior border of the scapula - This is incorrect as the vertebra prominens is located at the base of the neck, not opposite the scapula. D: Located next to the manubrium of the sternum - This is incorrect as the vertebra prominens is located higher up in the neck than the manubrium of the sternum.
Question 2 of 5
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?
Correct Answer: D
Rationale: The correct answer is D because the statement accurately describes colostrum, the first milk produced during pregnancy. Colostrum is a thick, yellow fluid that can be expressed from the breasts as early as the fourth month of pregnancy. It is rich in antibodies and nutrients essential for the newborn. A: Incorrect. Breast milk does not immediately appear after delivery; it takes a few days for mature milk to come in. B: Incorrect. Breast milk is rich in fat, not just protein and sugars. Fat is crucial for a baby's growth and development. C: Incorrect. Colostrum is a nutrient-rich fluid that provides essential nutrients to the newborn, even though it may not have the same composition as mature breast milk. In summary, choice D is correct because it accurately describes the early milk production during pregnancy, while the other choices provide inaccurate information about breast milk.
Question 3 of 5
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities. A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.
Question 4 of 5
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
Correct Answer: B
Rationale: The correct answer is B because listening in a rough Z pattern allows the nurse to cover all areas where heart sounds can be best heard - aortic, pulmonic, tricuspid, and mitral. This technique ensures a systematic approach to auscultation, starting at the base of the heart and moving towards the apex where the mitral area is located. By inching the stethoscope in this pattern, the nurse can accurately identify any abnormalities in heart sounds. Choice A is incorrect as it does not provide a systematic approach to auscultation and may lead to missing certain areas. Choice C is incorrect as heart sounds should be listened to at all relevant areas, not just where the apical pulse is strongest. Choice D is incorrect as listening for all possible sounds at once may lead to confusion and missing subtle abnormalities.
Question 5 of 5
A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have?
Correct Answer: A
Rationale: The correct answer is A: Acute orchitis. Orchitis is inflammation of the testicle, commonly caused by a viral infection (e.g., mumps) or a bacterial infection. In this case, the teenager presents with a swollen, tender left testicle, redness, and fever. The history of recent upper respiratory symptoms suggests a viral cause. Epididymitis (choice B) typically presents with pain in the scrotum and inflammation of the epididymis. Torsion of the spermatic cord (choice C) is a surgical emergency with sudden onset severe pain, absent cremasteric reflex, and high-riding testicle. Prostatitis (choice D) presents with symptoms like dysuria, pelvic pain, and fever, but the prostate exam here is unremarkable. Therefore, based on the clinical presentation and examination findings, the most likely diagnosis is acute orchitis.