ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
A 62-year-old smoker complains of 'coughing up small amounts of blood,' so you consider hemoptysis. Which of the following should you also consider?
Correct Answer: C
Rationale: The correct answer is C: Epistaxis. When a 62-year-old smoker presents with coughing up blood, hemoptysis is considered. Epistaxis, or nosebleed, should also be considered due to the proximity of the nasal passages to the throat. Smoking can cause irritation and inflammation, leading to epistaxis. Intestinal bleeding (choice A) is less likely due to the symptoms described. Hematoma of the nasal septum (choice B) and bruising of the tongue (choice D) are not directly related to the symptoms presented.
Question 2 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 3 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 4 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.
Question 5 of 5
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
Correct Answer: B
Rationale: The correct answer is B because leaving the thermometer in place for 3 to 4 minutes allows for an accurate reading of oral temperature. This duration ensures the mercury in the thermometer reaches equilibrium with the body temperature. Choice A is incorrect as waiting 30 minutes after ingesting hot or iced liquids is unnecessary for assessing oral temperature. Choice C is incorrect as placing the thermometer in front of the tongue and asking the patient to close their lips may not provide an accurate reading. Choice D is incorrect as shaking the thermometer down before taking the temperature is not necessary and can introduce errors in the reading.