ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia?
Correct Answer: B
Rationale: The correct answer is B: Imbalance of hormones of puberty. Gynecomastia in adolescent males is commonly caused by hormonal changes during puberty, where there may be an imbalance between estrogen and testosterone levels leading to breast tissue enlargement. In this case, the patient's denial of tobacco, alcohol, or drug use, along with his age and physical exam findings consistent with puberty changes, support the hormonal imbalance as the likely cause. Breast cancer (A) is less likely in a young male without other concerning symptoms or risk factors. While drug use (C) can also cause gynecomastia, the patient's denial and willingness to take a drug test make it less likely in this scenario.
Question 2 of 5
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:
Correct Answer: C
Rationale: The correct answer is C because when a patient is transitioning from the intensive care unit to a medical-surgical unit after being in ICU for a prolonged period, it is common for them to be disoriented regarding the date due to the change in environment and routine. Being oriented to place and person indicates intact cognitive function. - Choice A is incorrect because disruption in thought content is not typically expected in this scenario. - Choice B is incorrect as the patient expressing relief does not provide information about cognitive function. - Choice D is incorrect as clouding of consciousness is not expected during a routine mental status examination in this context.
Question 3 of 5
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
Correct Answer: D
Rationale: The correct answer is D because it directly acknowledges the situation while also establishing the purpose of the conversation. By addressing Mrs. H. by name and explaining the need to ask about what happened, the nurse shows empathy, professionalism, and sets the tone for a confidential and supportive interaction. Choice A is incorrect because it lacks specificity and fails to address the immediate concerns of the patient. Choice B is incorrect as it diverts from the primary issue by commenting on the weather. Choice C is incorrect as it jumps straight into asking how the patient is without acknowledging the reason for the visit, which may not be appropriate given the circumstances.
Question 4 of 5
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ________ of the underlying tissue.
Correct Answer: C
Rationale: Percussion is used to assess the density of underlying tissue by producing sound waves and evaluating the quality of sound produced. Density refers to the compactness of tissue, which can help identify abnormalities such as fluid or air accumulation. Turgor (A) is the skin's elasticity, not assessed by percussion. Texture (B) refers to the feel of the tissue, not evaluated through percussion. Consistency (D) is the uniformity of tissue, which is not primarily assessed by percussion. Therefore, the correct answer is C as it directly relates to the purpose of percussion in assessing underlying tissue density.
Question 5 of 5
During the examination, which action by the nurse helps reduce patient anxiety?
Correct Answer: C
Rationale: The correct answer is C because offering brief teaching during the exam helps reduce patient anxiety by providing information and reassurance. This action fosters a sense of understanding and involvement, empowering the patient. Explaining findings in simple terms can alleviate confusion and fear. Maintaining a hurried demeanor (B) can increase anxiety due to perceived lack of care. Avoiding discussion (D) may lead to feelings of neglect. Using medical terminology (A) can further confuse and distress the patient, worsening anxiety.