ATI RN
Vital Signs Assessment Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is conducting a pain assessment. Which question best evaluates the quality of the patient's pain?
Correct Answer: B
Rationale: The correct answer is B: What does the pain feel like? This question is best for evaluating the quality of pain because it helps determine the characteristics and nature of the pain, such as sharp, dull, throbbing, burning, etc. Understanding the specific qualities of pain can provide valuable insights into possible causes and appropriate interventions. A: When did the pain start? This question assesses the onset of pain, not its quality. C: What makes the pain better or worse? This question evaluates exacerbating or alleviating factors, not the quality of pain. D: Where is the pain located? This question assesses the location of pain, not its quality.
Question 5 of 5
The nurse is auscultating heart sounds and notes a split S2 during inspiration. What does this finding indicate?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. During inspiration, the intrathoracic pressure decreases, causing the pulmonary artery to fill more slowly than the aorta, resulting in a split S2. This is a physiological phenomenon known as a respiratory split, which is considered normal. Choices B, C, and D are incorrect because they do not correlate with the specific finding of a split S2 during inspiration. Mitral valve regurgitation and aortic stenosis typically present with different auscultatory findings, while heart failure may manifest with additional signs and symptoms beyond just a split S2.