ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A 45-year-old woman with a history of hypertension presents with a complaint of headache, blurred vision, and nausea. Her blood pressure is 200/120 mm Hg. What is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Hypertensive crisis. The patient's symptoms of headache, blurred vision, and nausea, along with severely elevated blood pressure (200/120 mm Hg), suggest a hypertensive emergency. In this situation, the elevated blood pressure is causing end-organ damage, leading to symptoms. Treatment is urgent to prevent further complications. Choice A: Primary hypertension is unlikely as the sudden onset of severe symptoms and extremely high blood pressure indicate an acute issue rather than chronic primary hypertension. Choice C: Migraine typically presents with specific symptoms like throbbing head pain, sensitivity to light or sound, and may have an aura. The lack of these symptoms and the presence of severely elevated blood pressure make migraine less likely. Choice D: Cluster headaches are characterized by severe, unilateral head pain with associated symptoms like eye redness or tearing. The lack of these specific symptoms and the presence of markedly elevated blood pressure make cluster headache less likely.
Question 2 of 5
The nurse is performing a neurological assessment and asks the patient to walk in a straight line. The patient sways significantly and loses balance. What does this finding suggest?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar dysfunction. When a patient sways significantly and loses balance while walking in a straight line, it suggests dysfunction of the cerebellum. The cerebellum is responsible for coordination, balance, and fine motor control. Impairment in the cerebellum can lead to ataxia, which is characterized by uncoordinated movements and difficulty maintaining balance. Vestibular impairment (B) primarily affects the inner ear's balance system, not coordination of movement. Motor weakness (C) typically presents as muscle weakness and affects strength, not balance. Peripheral neuropathy (D) involves damage to peripheral nerves, leading to sensory and motor deficits, but not specifically related to coordination and balance issues like cerebellar dysfunction.
Question 3 of 5
The nurse is performing a neurological assessment and asks the patient to walk heel-to-toe. The patient staggers and loses balance. What does this finding suggest?
Correct Answer: A
Rationale: The correct answer is A: Cerebellar dysfunction. When a patient staggers and loses balance while walking heel-to-toe, it indicates impairment in coordination and balance control, which are functions of the cerebellum. The cerebellum plays a crucial role in coordinating voluntary movements and maintaining balance. Vestibular dysfunction (B) primarily affects the inner ear's balance system, leading to vertigo and dizziness, not staggering gait. Sensory neuropathy (C) affects sensation, not coordination, and would not cause a specific gait abnormality. Motor weakness (D) would manifest as difficulty with strength and muscle control, not coordination issues seen in cerebellar dysfunction.
Question 4 of 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a decreased range of motion in the shoulder with pain on movement. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Frozen shoulder (adhesive capsulitis). Frozen shoulder is characterized by decreased range of motion in the shoulder joint with pain on movement. This is due to inflammation and thickening of the shoulder joint capsule, leading to adhesions that restrict movement. Other choices are incorrect because: A: Osteoarthritis primarily affects the joints, causing pain and stiffness but typically doesn't lead to severe restriction of range of motion like in frozen shoulder. C: Rheumatoid arthritis is a systemic autoimmune disorder that can affect multiple joints, causing inflammation and deformities, but it doesn't typically present with the characteristic pattern of restricted movement seen in frozen shoulder. D: Bursitis involves inflammation of the bursae (fluid-filled sacs) around joints, leading to pain and swelling, but it doesn't typically result in the severe restriction of movement and pain on movement seen in frozen shoulder.
Question 5 of 5
Surface and Core:
Correct Answer: B
Rationale: Vital signs include measurable indicators like pulse, temperature, blood pressure, and sometimes pain, but the question Surface and Core specifically refers to temperature, making Choice B correct. Temperature can be measured at surface sites (e.g., skin, oral) or core sites (e.g., rectal, tympanic), reflecting internal body heat. Pulse, measures heart rate, not divided into surface and core. Blood pressure, assesses vascular pressure, not temperature distribution. Pain, is subjective and not measured in this dual context. The distinction between surface (less stable, affected by environment) and core (stable, reflecting true body temperature) is a key concept in nursing, especially when monitoring fever or hypothermia. Thus, B aligns with the questions focus on temperatures dual measurement nature.