ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
Correct Answer: D
Rationale: The forceful movement along the sternal border indicates right ventricular enlargement. This is because the right ventricle is located close to the sternum. Enlargement of the left ventricle (Choice C) typically causes a sustained apical impulse. A systolic murmur (Choice B) is usually heard during auscultation, not observed visually. A normal heart (Choice A) would not exhibit forceful movement along the sternal border. Therefore, the correct answer is D.
Question 2 of 5
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
Correct Answer: B
Rationale: The correct answer is B because prolonged bed rest can lead to decreased muscle contraction in the legs, slowing blood flow and increasing the risk of venous stasis and clot formation. This increases the risk of developing venous disease. A: Pregnancy increases pressure on veins but typically resolves postpartum. C: Smoking is a risk factor for arterial disease, not venous disease. D: Anticoagulants are used to prevent clot formation, reducing the risk of venous disease. In summary, choice B is correct because prolonged bed rest directly contributes to venous stasis and clot formation, making it the highest risk factor among the options provided.
Question 3 of 5
During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel 'heavy in the calf' and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
Correct Answer: B
Rationale: The correct answer is B: Varicose veins. The woman's symptoms of heavy legs, foot cramps, and dilated, tortuous veins in the lower legs are classic signs of varicose veins. Varicose veins occur due to weakened valves in the veins, leading to pooling of blood and vein enlargement. Deep-vein thrombophlebitis (choice A) presents with redness, warmth, and swelling in the affected limb, which are not mentioned. Lymphedema (choice C) is characterized by persistent swelling, typically in one limb, due to lymphatic system dysfunction, not dilated veins. Raynaud phenomenon (choice D) involves episodes of reduced blood flow to extremities, causing color changes and numbness, which are not indicated in this scenario.
Question 4 of 5
A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
Correct Answer: B
Rationale: Step 1: Calculate BMI: BMI = weight (kg) / height (m)^2 BMI = 19.5 kg / (1.65 m)^2 BMI = 19.5 kg / 2.72 m^2 BMI = 7.17 Step 2: Interpretation of BMI: BMI of 19.5 falls within the normal range (18.5-24.9) for a 15-year-old. Step 3: Rationale for Correct Answer (B): The correct answer is to reassure the mother that her daughter's BMI of 19.5 is normal for her age. There are no indicators of anorexia or obesity based on the BMI calculation. Step 4: Summary of Incorrect Choices: A: Referring to a nutritionist and psychologist for anorexia is incorrect as the BMI is within the normal range. C: Providing exercise information for obesity is incorrect as the BMI does not indicate obesity. D:
Question 5 of 5
For the following situations, state the type of data collection you would perform (i.e., complete database, focused or problem-centered database, follow-up database, emergency database). b. ambulatory, apparently well individual who presents at an outpatient clinic with a rash
Correct Answer: B
Rationale: The correct answer is B: Focused or problem-centered database. When dealing with an ambulatory, apparently well individual presenting with a rash at an outpatient clinic, a focused or problem-centered database is appropriate. This type of data collection focuses on the specific health issue or problem at hand, which in this case is the rash. It involves gathering information related to the current concern without the need for a comprehensive assessment of all body systems like in a complete database. Follow-up database is not applicable as this is the initial visit. Emergency database is not suitable as the individual is ambulatory and not in a critical condition needing immediate attention.