ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep. What form of vaginitis is this patient most likely to have?
Correct Answer: D
Rationale: The correct answer is D: Atrophic vaginitis. In this case, the patient is a postmenopausal woman with vaginal dryness, redness, and easy bleeding, which are typical symptoms of atrophic vaginitis due to decreased estrogen levels. The absence of discharge, negative KOH whiff test, and lack of clue cells rule out Trichomonas vaginitis, Candida vaginitis, and bacterial vaginosis respectively. The smaller labia and absence of other significant findings on examination support the diagnosis of atrophic vaginitis. Menopause-related changes in the vaginal tissues lead to the symptoms described in this patient.
Question 2 of 5
Which of the following anatomic landmark associations is correct?
Correct Answer: A
Rationale: The correct answer is A. In tension pneumothorax, needle decompression is performed at the 2nd intercostal space in the midclavicular line to release trapped air. This location ensures proper decompression of the pleural space. Choice B is incorrect because T6 is typically the level for the lower margin of the endotracheal tube, not the insertion point. Choice C is incorrect as the sternal angle corresponds to the 2nd rib, not the 4th rib. Choice D is incorrect as the 5th intercostal space is commonly used for chest tube insertion to drain the pleural space, not for needle decompression in tension pneumothorax.
Question 3 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 4 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 5 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.