ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):
Correct Answer: B
Rationale: The correct answer is B: Acute otitis media. In this case, the bright red tympanic membrane and the absence of the light reflex suggest inflammation and infection of the middle ear, which are characteristic of acute otitis media. The child's symptoms of pulling on his ear also support this diagnosis. A: Fungal infection typically presents with white patches and not necessarily redness or absence of light reflex. C: Perforation of the eardrum would show a visible hole in the tympanic membrane. D: Cholesteatoma is a noncancerous growth that would present differently on otoscopic examination.
Question 2 of 5
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
Correct Answer: D
Rationale: The correct response is D. Using nasal medications can irritate the nasal lining, leading to rebound swelling, which causes the medication to become less effective over time. This explains why the woman's nasal spray is not working as well as before. It is important for the nurse to address this issue to prevent worsening of symptoms. Choice A is incorrect as not all over-the-counter nasal sprays carry a risk of addiction. Choice B is not the best response as switching brands may not address the underlying issue of rebound swelling. Choice C is incorrect as it does not address the potential problem of rebound swelling caused by the nasal spray.
Question 3 of 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
Correct Answer: B
Rationale: The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management. Incorrect choices: A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold. C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent. D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.
Question 4 of 5
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? Tell the mother that:
Correct Answer: C
Rationale: The correct answer is C because unilateral breast enlargement with tenderness in a 10-year-old girl is most likely due to normal breast development, known as thelarche. The nurse should reassure the mother that it is common for breast development to be asymmetric initially and that an examination can confirm this. This response is appropriate because breast cancer is extremely rare in preadolescent girls, making option B incorrect. Option A is incorrect as immediate examination is not necessary unless there are other concerning symptoms. Option D is incorrect as breast tenderness can occur during breast development due to hormonal changes. Thus, option C is the best response based on the presentation and age of the patient.
Question 5 of 5
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Correct Answer: A
Rationale: Rationale: Position A (Supine with the arms raised over her head) is most likely to make significant lumps more distinct during breast palpation because raising the arms stretches the breast tissue, making abnormalities easier to feel. This position allows for better access to all areas of the breast. In contrast, choices B (Sitting with the arms relaxed at her sides) and C (Supine with the arms relaxed at her sides) do not provide the same level of breast tissue stretching, making it harder to detect lumps. Choice D (Sitting with the arms flexed and fingertips touching her shoulders) may limit the nurse's ability to fully palpate the breast due to the arms being in the way.