ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
A physical therapist evaluates a patient with adhesive capsulitis of the shoulder. Which intervention is MOST appropriate to improve range of motion?
Correct Answer: A
Rationale: The correct answer is A: Joint mobilization. Joint mobilization involves skilled passive movement techniques applied to a joint to restore motion. In adhesive capsulitis, there is restricted motion due to adhesions within the joint capsule. Joint mobilization helps break down these adhesions, improving range of motion. Electrical stimulation (B) and ultrasound therapy (C) may help with pain management but do not directly address the joint restriction. Postural training (D) may be beneficial for overall shoulder function but is not the most direct intervention for improving range of motion in adhesive capsulitis.
Question 2 of 5
During a skin assessment, the nurse observes a patient's mole and notes that it has an irregular border, varied colors, and a diameter of 8 mm. What is the appropriate action?
Correct Answer: C
Rationale: The correct answer is C: Refer the patient for further evaluation. The patient's mole exhibits characteristics associated with melanoma, such as irregular border, varied colors, and a diameter larger than 6 mm (8 mm in this case). Referring the patient for further evaluation by a dermatologist or healthcare provider specializing in skin assessments is crucial for prompt diagnosis and appropriate treatment if necessary. Options A, B, and D are incorrect because ignoring or delaying evaluation of suspicious moles can lead to potential complications or missed opportunities for early intervention in case of skin cancer.
Question 3 of 5
The nurse is auscultating the lungs and hears low-pitched, soft sounds over the peripheral lung fields. How should this finding be documented?
Correct Answer: C
Rationale: The correct answer is C: Vesicular breath sounds. These are low-pitched, soft sounds heard over the peripheral lung fields during normal breathing. This finding should be documented as vesicular breath sounds because they are expected in healthy individuals. Choice A: Bronchial breath sounds are high-pitched and loud, heard over the trachea and large airways, not the peripheral lung fields. Choice B: Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, typically heard over the mainstem bronchi, not the peripheral lung fields. Choice D: Adventitious breath sounds refer to abnormal lung sounds like crackles or wheezes, not the soft, low-pitched sounds described in the scenario.
Question 4 of 5
Which physical assessment finding is most indicative of chronic hypoxia?
Correct Answer: B
Rationale: The correct answer is B: Clubbing of the fingers. Clubbing is a sign of chronic hypoxia due to prolonged oxygen deprivation, leading to changes in the nails and fingertips. This occurs in conditions like chronic lung disease. Barrel chest (choice A) is typically seen in emphysema due to lung hyperinflation. Use of accessory muscles (choice C) and intercostal retractions (choice D) are signs of acute respiratory distress, not chronic hypoxia.
Question 5 of 5
A 25-year-old woman presents with a complaint of fatigue and muscle weakness. On examination, she has ptosis and weakness of the proximal muscles of the upper limbs. Her vital signs are stable, and laboratory tests reveal a positive anti-acetylcholine receptor antibody test. Which of the following is the most likely diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Myasthenia gravis. This autoimmune disorder is characterized by muscle weakness and fatigability due to antibodies attacking acetylcholine receptors at the neuromuscular junction. The presence of anti-acetylcholine receptor antibodies in this patient supports the diagnosis. Ptosis and weakness of proximal muscles are classic features. Choice A, Multiple sclerosis, is a central nervous system disorder and typically presents with sensory and motor deficits, not ptosis or fluctuating weakness. Guillain-Barré syndrome (Choice C) is characterized by ascending weakness and is typically preceded by an infection, unlike the chronic presentation in myasthenia gravis. Lambert-Eaton syndrome (Choice D) involves antibodies against presynaptic calcium channels and presents with proximal muscle weakness but often includes autonomic symptoms, which are not evident in this patient.