ATI RN
Vital Signs Assessment Questions
Question 1 of 5
A patient with a head injury opens the eyes to painful stimulation, mumbles incoherently when stimulated, and does not respond to a verbal command to move but localizes to painful stimulus. The nurse records the patient's Glasgow Coma Scale score as:
Correct Answer: B
Rationale: The correct answer is B: 11. According to the Glasgow Coma Scale (GCS), this patient scores 4 for eye opening (to painful stimulus), 3 for verbal response (mumbles incoherently), and 4 for motor response (localizes to painful stimulus), totaling 11. This indicates moderate brain injury. Choice A (9) is incorrect because the patient localizes to pain, indicating a higher level of responsiveness than a GCS score of 9. Choice C (13) and D (15) are also incorrect as the patient's responses do not align with a higher GCS score due to the patient's inability to follow verbal commands effectively.
Question 2 of 5
During a neurological assessment, the nurse tests cranial nerve VII. What is the primary function of this nerve?
Correct Answer: B
Rationale: The correct answer is B: Facial movements and expression. Cranial nerve VII, also known as the facial nerve, primarily controls facial muscles responsible for facial expressions, such as smiling and frowning. It also innervates the muscles involved in closing the eyes and controlling the forehead and mouth movements. Other choices are incorrect because cranial nerve VII is not primarily responsible for hearing and balance (A), swallowing and speech (C), or eye movement (D). The key function of cranial nerve VII lies in its role in facial movements and expressions.
Question 3 of 5
Which of the following findings is most concerning during a peripheral vascular assessment?
Correct Answer: C
Rationale: The correct answer is C, unilateral edema. This finding is most concerning as it may indicate a blockage or dysfunction in the lymphatic or venous system, potentially leading to serious conditions like deep vein thrombosis. In contrast, A and D are normal findings indicating good peripheral circulation, while B is also normal and indicates balanced blood flow.
Question 4 of 5
During a skin assessment, the nurse notes a lesion with irregular borders and varied colors. What is the next action?
Correct Answer: B
Rationale: The correct answer is B: Refer the patient for further evaluation. This is because the lesion with irregular borders and varied colors raises concern for possible skin cancer. Referring the patient for further evaluation by a dermatologist is crucial to determine the nature of the lesion and initiate appropriate treatment. Documenting it as a normal finding (choice A) is incorrect as it may delay necessary intervention. Applying an antibiotic ointment (choice C) is not indicated as the lesion is not suggestive of infection. Reassessing the lesion in one month (choice D) could lead to a delay in diagnosis and treatment if the lesion is indeed malignant.
Question 5 of 5
Which of the following findings during a cardiovascular assessment indicates poor oxygenation?
Correct Answer: B
Rationale: The correct answer is B: Cyanosis of the lips and nail beds. Cyanosis indicates poor oxygenation due to the bluish discoloration of the lips and nail beds, suggesting insufficient oxygen in the blood. Capillary refill time less than 2 seconds (A) is a normal finding indicating good perfusion. Warm and pink extremities (C) also suggest good circulation. Bounding peripheral pulses (D) can be associated with increased cardiac output but do not directly indicate poor oxygenation.