ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Breast tissue. In a 30-year-old male with a firm, 2-cm mass under the areola and no other symptoms, the most likely diagnosis is normal breast tissue development or gynecomastia. This condition is common in males and usually resolves on its own. Fibrocystic disease (B) is more common in females and presents with multiple cysts. Breast cancer (C) is less likely in this age group and without other concerning symptoms. Lymph node (D) is unlikely as the mass is described as under the areola, not in the axilla.
Question 2 of 5
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
Correct Answer: C
Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This test assesses new memory by asking the patient to remember and recall four unrelated words after a short delay. This is an effective way to specifically target the assessment of new memory function. Administering the FACT test (A) may assess different cognitive functions, not specifically new memory. Asking the patient to describe his first job (B) tests long-term memory, not new memory. Asking about the television show (D) before coming to the clinic does not directly assess new memory.
Question 3 of 5
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
Correct Answer: D
Rationale: The correct answer is D because it directly asks for the specific information needed without making assumptions or being overly suggestive. It is important to gather accurate and relevant information about past hospitalizations. Choice A is incorrect as it is presumptuous and can be seen as ageist. Choice B is incorrect as it assumes the patient's consent without explicitly asking. Choice C is incorrect as it assumes the patient mentioned past hospitalizations without confirming, and it is vague in requesting details. The best approach is to ask directly for the specific information needed, as in choice D.
Question 4 of 5
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
Correct Answer: A
Rationale: The correct answer is A: Consider this a normal finding. The liver typically produces a dull sound upon percussion due to its solid nature. This is considered a normal finding as the liver is a solid organ. Palpation for an underlying mass (Choice B) is not necessary based solely on the dull percussion sound. Repositioning hands and percussing again (Choice C) is unlikely to change the result. Referring the patient for additional treatment (Choice D) is premature without further assessment. Therefore, A is the correct choice based on the expected percussion sound over the liver.
Question 5 of 5
The nurse is assessing an older adult. Which action is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Minimize position changes during the exam. This is the most appropriate action because older adults may have mobility issues, so minimizing position changes helps prevent discomfort and potential injury. Speaking loudly (choice C) is not necessary unless the patient has hearing impairments. Completing the exam in one session (choice A) may be overwhelming and tiring for the patient. Performing a quick exam (choice D) may compromise the thoroughness of the assessment.