ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
A nurse is taking a patients temperature and wants the most accurate measurement, based on core body temperature. What site should be used?
Correct Answer: A
Rationale: Rectal provides the most accurate core temperature, per the answer key, reflecting internal heat near the hypothalamus. Oral , axillary , and forehead are less precise. Nurses choose rectal for its reliability in critical assessments despite invasiveness.
Question 2 of 5
An 18-year-old college freshman comes to your clinic, complaining of severe left-sided lower abdominal pain and a foul yellow discharge. The pain began last night while she was having intercourse with her boyfriend. Afterward the pain became more severe and the discharge started. By this morning she had a fever of 101 degrees and walking was making the pain worse. Only lying very still makes the pain better. She has tried ibuprofen and acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. Her past medical history is unremarkable. She has had two past sexual partners. She uses the birth control patch instead of condoms. She smokes a half pack of cigarettes a day and drinks four to five beers per weekend night. She denies any illegal drug use. Her parents are both healthy. On examination you find a young woman who appears ill. Her temperature is 102 degrees and her pulse is elevated at 110. She is tender in the left lower quadrant but has no guarding or rebound. Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness and the left adnexa is swollen and tender. A urine analysis is unremarkable and the urine pregnancy test is pending. What is the best choice of diagnosis for this adnexal swelling?
Correct Answer: C
Rationale: The correct diagnosis is C: Pelvic inflammatory disease (PID). The patient's symptoms of severe left-sided lower abdominal pain, foul yellow discharge, fever, tenderness in the left lower quadrant, cervical motion tenderness, and swollen/tender left adnexa are indicative of PID. The history of recent intercourse, multiple sexual partners, and use of birth control patch instead of condoms increase the risk of sexually transmitted infections, leading to PID. The key findings on examination, such as purulent drainage, cervical motion tenderness, and adnexal tenderness, support the diagnosis. PID is a serious infection that can lead to complications like infertility and ectopic pregnancy if not treated promptly. Incorrect choices: A: Ovarian cyst - Unlikely as symptoms are more indicative of an infectious process rather than a simple cyst. B: Tubal pregnancy - While a tubal pregnancy can present with lower abdominal pain and a positive pregnancy test, the presence of purulent discharge and cervical motion tenderness suggests
Question 3 of 5
A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Breast tissue. In a 30-year-old male with a firm, 2-cm mass under the areola and no other symptoms, the most likely diagnosis is normal breast tissue development or gynecomastia. This condition is common in males and usually resolves on its own. Fibrocystic disease (B) is more common in females and presents with multiple cysts. Breast cancer (C) is less likely in this age group and without other concerning symptoms. Lymph node (D) is unlikely as the mass is described as under the areola, not in the axilla.
Question 4 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 5 of 5
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
Correct Answer: C
Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This test assesses new memory by asking the patient to remember and recall four unrelated words after a short delay. This is an effective way to specifically target the assessment of new memory function. Administering the FACT test (A) may assess different cognitive functions, not specifically new memory. Asking the patient to describe his first job (B) tests long-term memory, not new memory. Asking about the television show (D) before coming to the clinic does not directly assess new memory.