ATI RN
Neurological Vital Signs Assessment Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
Correct Answer: D
Rationale: The correct answer is D because it directly asks for the specific information needed without making assumptions or being overly suggestive. It is important to gather accurate and relevant information about past hospitalizations. Choice A is incorrect as it is presumptuous and can be seen as ageist. Choice B is incorrect as it assumes the patient's consent without explicitly asking. Choice C is incorrect as it assumes the patient mentioned past hospitalizations without confirming, and it is vague in requesting details. The best approach is to ask directly for the specific information needed, as in choice D.
Question 5 of 5
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
Correct Answer: A
Rationale: The correct answer is A: Consider this a normal finding. The liver typically produces a dull sound upon percussion due to its solid nature. This is considered a normal finding as the liver is a solid organ. Palpation for an underlying mass (Choice B) is not necessary based solely on the dull percussion sound. Repositioning hands and percussing again (Choice C) is unlikely to change the result. Referring the patient for additional treatment (Choice D) is premature without further assessment. Therefore, A is the correct choice based on the expected percussion sound over the liver.