ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
Correct Answer: B
Rationale: The correct answer is B: Impetigo. Impetigo presents with moist, thin-roofed vesicles with a thin erythematous base, commonly found on the face and buttocks. The vesicles rupture, forming honey-colored crusts. The history of a new babysitter suggests exposure to skin infections. Eczema (choice A) presents with dry, scaly patches. Herpes zoster (choice C) presents with grouped vesicles along a dermatome. Diaper dermatitis (choice D) presents with erythema and scaling in the diaper area. The key features in this case match impetigo, making it the correct choice.
Question 2 of 5
The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?
Correct Answer: D
Rationale: The correct answer is D: The purpose of the tubes is to decrease the pressure and allow for drainage. Tympanostomy tubes are inserted into the eardrum to allow for drainage of fluid from the middle ear, decreasing pressure and preventing recurrent ear infections. This is important for the child's hearing and overall health. A: The tubes are not placed in the inner ear. They are placed in the eardrum to assist in drainage. B: Tympanostomy tubes are not used for sensorineural loss, but rather for conditions like recurrent ear infections or fluid buildup in the middle ear. C: The tubes are not permanently inserted during a surgical procedure. They are typically temporary and will eventually fall out on their own.
Question 3 of 5
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?
Correct Answer: C
Rationale: Rationale: Choice C is correct because bluish lips and a dark line along the gingival margin are normal pigmentation variations seen in individuals with darker skin tones, especially in Black patients. This is known as racial pigmentation and does not indicate any health concern. Choices A, B, and D are incorrect as they are not relevant to this specific physical finding and may lead to unnecessary testing or interventions. Checking hemoglobin, assessing for oxygen supply, and inquiring about carbon monoxide exposure are not indicated based on the racial pigmentation seen in this patient.
Question 4 of 5
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
Correct Answer: B
Rationale: The correct answer is B: A bifid uvula may occur in some Native-American groups. A bifid uvula refers to a split or forked uvula, which is a variation of normal anatomy and can be seen in certain populations, including some Native-American groups. This condition is usually benign and does not typically cause any health issues. It is important for healthcare providers to be aware of such variations to avoid unnecessary concern or intervention. Explanation for incorrect options: A: This condition is not a cleft palate, which is a more severe congenital condition involving a gap in the roof of the mouth. C: There is no indication that the bifid uvula is due to an injury or that it should be reported to authorities. D: "Palatinus" is not a term commonly used to describe a bifid uvula, and the statement about its frequency in Native Americans is not supported by evidence.
Question 5 of 5
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
Correct Answer: C
Rationale: The correct answer is C because bronchovesicular breath sounds in the peripheral lung fields are an expected finding in a 4-year-old child. This is due to the normal anatomy and physiology of a child's respiratory system at that age. Bronchovesicular breath sounds are commonly heard in children and are a combination of bronchial and vesicular sounds. These sounds are normal in children up to the age of 5 and are typically heard in the peripheral lung fields. Choice A is incorrect because crepitus palpated at the costochondral junctions is not an expected finding in a 4-year-old child's respiratory assessment. Crepitus may indicate air or gas under the skin and is not a normal finding in a respiratory assessment. Choice B is incorrect because no diaphragmatic excursion due to decreased inspiratory volume is not a typical finding in a 4-year-old child. Children of this age should have adequate diaphragmatic excursion, and a lack of it may indicate respiratory