ATI RN
CNS Vital Signs Assessment Questions
Question 1 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 2 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.
Question 3 of 5
During the examination, which action by the nurse helps reduce patient anxiety?
Correct Answer: C
Rationale: The correct answer is C because offering brief teaching during the exam helps reduce patient anxiety by providing information and reassurance. This action fosters a sense of understanding and involvement, empowering the patient. Explaining findings in simple terms can alleviate confusion and fear. Maintaining a hurried demeanor (B) can increase anxiety due to perceived lack of care. Avoiding discussion (D) may lead to feelings of neglect. Using medical terminology (A) can further confuse and distress the patient, worsening anxiety.
Question 4 of 5
A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:
Correct Answer: C
Rationale: The correct answer is C: Unexplained weight loss often accompanies short-term illnesses. In this case, the patient has been treated for pneumonia for the past 6 weeks, which is a short-term illness. Weight loss in this context could be due to factors like increased metabolic rate or decreased appetite related to the illness. Choice A is incorrect because the weight loss is unexplained, not necessarily due to unhealthy eating habits. Choice B is incorrect as hypertension is not typically associated with significant weight loss. Choice D is incorrect as there is no indication in the scenario provided that the weight loss is due to a mental health dysfunction.
Question 5 of 5
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
Correct Answer: B
Rationale: The correct answer is B: The change in blood pressure readings is called orthostatic hypotension. This is because the blood pressure drop of 50/30 mm Hg between lying and standing positions meets the criteria for orthostatic hypotension (a drop of 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing). Choice A is incorrect as these readings indicate orthostatic hypotension, not just a normal response to position changes. Choice C is incorrect because the lying position reading is elevated for a 70-year-old. Choice D is incorrect as the significant drop in blood pressure is not considered within normal limits for the patient's age.