ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?
Correct Answer: C
Rationale: Rationale: Choice C is correct because bluish lips and a dark line along the gingival margin are normal pigmentation variations seen in individuals with darker skin tones, especially in Black patients. This is known as racial pigmentation and does not indicate any health concern. Choices A, B, and D are incorrect as they are not relevant to this specific physical finding and may lead to unnecessary testing or interventions. Checking hemoglobin, assessing for oxygen supply, and inquiring about carbon monoxide exposure are not indicated based on the racial pigmentation seen in this patient.
Question 2 of 5
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
Correct Answer: C
Rationale: The correct answer is C because bronchovesicular breath sounds in the peripheral lung fields are an expected finding in a 4-year-old child. This is due to the normal anatomy and physiology of a child's respiratory system at that age. Bronchovesicular breath sounds are commonly heard in children and are a combination of bronchial and vesicular sounds. These sounds are normal in children up to the age of 5 and are typically heard in the peripheral lung fields. Choice A is incorrect because crepitus palpated at the costochondral junctions is not an expected finding in a 4-year-old child's respiratory assessment. Crepitus may indicate air or gas under the skin and is not a normal finding in a respiratory assessment. Choice B is incorrect because no diaphragmatic excursion due to decreased inspiratory volume is not a typical finding in a 4-year-old child. Children of this age should have adequate diaphragmatic excursion, and a lack of it may indicate respiratory
Question 3 of 5
During an annual examination, a girl states that she is concerned about her development. She asks the nurse when she will get breasts. In obtaining a health history, the nurse should ascertain which of the following? The age that:
Correct Answer: A
Rationale: The correct answer is A: The girl began to develop breasts. This is crucial to determine her stage of puberty. Breast development typically starts before other secondary sexual characteristics, making it a key indicator. Knowing the age of breast development helps assess if she is within the normal range or needs further evaluation. B: Her mother developed breasts - irrelevant to the girl's current development. C: She began to develop pubic hair - secondary sexual characteristic but not as indicative as breast development. D: She began to develop axillary hair - less reliable marker of puberty compared to breast development.
Question 4 of 5
Which of these clinical situations would the nurse consider to be outside normal limits?
Correct Answer: D
Rationale: The correct answer is D because the presence of thick yellow discharge from both nipples in a patient who has had two pregnancies and breastfed her children is outside the normal limits. This could indicate a condition such as galactorrhea, which is abnormal lactation unrelated to breastfeeding. The discharge may be due to hormonal imbalances or other underlying issues that require further investigation. Explanation for other choices: A: Soft and slightly sagging breasts in a patient entering menopause can be considered within normal limits due to hormonal changes. B: Firm, transverse ridges along the lower quadrant of breasts in a patient who has never been pregnant may indicate fibrocystic changes, which are common and typically not concerning. C: Nodular and engorged breast tissue with slight pain before menstruation is a common premenstrual symptom and is usually within normal limits.
Question 5 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.