ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
Correct Answer: D
Rationale: The correct answer is D: Melanocytes. Melanocytes are responsible for producing melanin, the pigment that gives hair its color. As individuals age, the number of functioning melanocytes decreases, leading to a loss of pigment in the hair, resulting in gray or white hair. Metrocytes (A), Fungacytes (B), and Phagocytes (C) are not involved in hair pigmentation, making them incorrect choices in this context.
Question 2 of 5
The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?
Correct Answer: D
Rationale: The correct answer is D because the eustachian tube helps equalize air pressure on both sides of the tympanic membrane. This is important for maintaining proper function of the middle ear. The other choices are incorrect because: A) Cerumen is produced by the ceruminous glands, not the eustachian tube. B) The eustachian tube normally remains closed and only opens during swallowing, yawning, or sneezing to equalize pressure. C) The eustachian tube connects the middle ear to the nasopharynx, not the outer ear.
Question 3 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 4 of 5
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
Correct Answer: A
Rationale: The correct answer is A. Asking the patient if they are aware of having any allergies is the most appropriate question as the presentation of pale, gray, and swollen nasal mucosa could be indicative of an allergic reaction. By inquiring about allergies, the nurse can gather crucial information to potentially identify the cause of the nasal mucosa changes. Choice B ("Do you have an elevated temperature?") is incorrect as the symptoms described are more specific to nasal mucosa changes rather than a systemic infection. Choice C ("Have you had any symptoms of a cold?") is incorrect as the symptoms do not necessarily align with a typical cold presentation. Choice D ("Have you been having frequent nosebleeds?") is incorrect as it does not directly address the current observation of pale, gray, and swollen nasal mucosa.
Question 5 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.