ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?
Correct Answer: D
Rationale: The correct answer is D because the presentation of a tender, reddish-blue auricle with vesicles suggests frostbite, which is caused by prolonged exposure to extreme cold. Understanding the patient's exposure to cold is crucial for proper treatment. A: Change in ability to hear is not directly related to the physical findings described. B: Recent drainage from the ear is not typically associated with the described symptoms. C: While trauma may cause similar symptoms, the presentation of vesicles is more indicative of frostbite rather than trauma.
Question 2 of 5
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
Correct Answer: C
Rationale: The correct answer is C: Rheumatic fever. Strep throat is caused by group A Streptococcus bacteria. If left untreated, the bacteria can lead to an autoimmune response, causing rheumatic fever. This condition can result in inflammation and damage to the heart, joints, and other tissues. Rubella (A) is a viral infection unrelated to strep throat. Leukoplakia (B) is a precancerous condition of the mouth. Scarlet fever (D) is a complication of strep throat but is characterized by a rash and not the autoimmune response seen in rheumatic fever.
Question 3 of 5
The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
Correct Answer: B
Rationale: Step-by-step rationale for choice B (Decreased mobility of the thorax) as the correct answer: 1. With aging, the rib cage becomes less flexible, leading to decreased thoracic mobility. 2. This decrease in thoracic mobility is a normal finding in older adults due to changes in the musculoskeletal system. 3. Assessing for decreased thoracic mobility is important as it can impact respiratory function and overall health. Summary: A: Increased thoracic expansion is not a normal finding in older adults as aging typically results in decreased flexibility. C: Decreased anteroposterior diameter may occur in certain conditions but is not a consistent normal finding in older adults. D: Bronchovesicular breath sounds throughout the lungs are not specific to assessing the respiratory system in older adults.
Question 4 of 5
A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D because it provides reassurance based on the typical age range for breast development in girls, which is between 8 and 10 years old. By stating this, the nurse acknowledges the girl's concerns and normalizes her experience. Option A is not as specific and may not address the girl's worries directly. Option B personalizes the response, which may not be helpful in this situation. Option C focuses on menstruation, which is not directly related to breast development and may cause unnecessary anxiety. In summary, option D is the best response as it provides accurate information and reassurance tailored to the girl's concerns.
Question 5 of 5
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
Correct Answer: D
Rationale: The correct answer is D. When a woman slowly lifts her arms above her head during a breast examination, it allows for better visualization and detection of any nipple or skin retraction. This position stretches the breast tissue and skin, making any abnormalities more apparent. Additionally, observing for any lag or retraction in movement while the arms are raised can help identify any potential issues. Choice A is incorrect because bending over and touching her toes does not provide the necessary positioning to properly assess for nipple and skin retraction. Choice B is incorrect because lying down on the left side may not provide the same level of stretching and visibility as lifting the arms above the head. Choice C is incorrect because shifting from a supine position to a standing position may not provide the optimal angle for assessing nipple and skin retraction.