ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?
Correct Answer: B
Rationale: Irregular waveform suggests sensor issues; reapplying on another finger ensures accuracy. It's not normal . Distress or provider action follows if persistent. Choice B is correct, per the explanation, troubleshooting first in nursing practice.
Question 2 of 5
A school nurse is preparing to test the auditory function of grade school students. What equipment will be needed for this examination?
Correct Answer: A
Rationale: A tuning fork , per the answer key, tests hearing via vibration (e.g., Rinne, Weber tests). Percussion hammers , speculums , and ophthalmoscopes assess reflexes, nose/ears, or eyes. Nurses, per Taylor, use this for efficient auditory screening in schools.
Question 3 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 4 of 5
A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia?
Correct Answer: B
Rationale: The correct answer is B: Imbalance of hormones of puberty. Gynecomastia in adolescent males is commonly caused by hormonal changes during puberty, where there may be an imbalance between estrogen and testosterone levels leading to breast tissue enlargement. In this case, the patient's denial of tobacco, alcohol, or drug use, along with his age and physical exam findings consistent with puberty changes, support the hormonal imbalance as the likely cause. Breast cancer (A) is less likely in a young male without other concerning symptoms or risk factors. While drug use (C) can also cause gynecomastia, the patient's denial and willingness to take a drug test make it less likely in this scenario.
Question 5 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.