ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
During the examination, which action by the nurse helps reduce patient anxiety?
Correct Answer: C
Rationale: The correct answer is C because offering brief teaching during the exam helps reduce patient anxiety by providing information and reassurance. This action fosters a sense of understanding and involvement, empowering the patient. Explaining findings in simple terms can alleviate confusion and fear. Maintaining a hurried demeanor (B) can increase anxiety due to perceived lack of care. Avoiding discussion (D) may lead to feelings of neglect. Using medical terminology (A) can further confuse and distress the patient, worsening anxiety.
Question 2 of 5
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
Correct Answer: B
Rationale: The correct answer is B: The change in blood pressure readings is called orthostatic hypotension. This is because the blood pressure drop of 50/30 mm Hg between lying and standing positions meets the criteria for orthostatic hypotension (a drop of 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing). Choice A is incorrect as these readings indicate orthostatic hypotension, not just a normal response to position changes. Choice C is incorrect because the lying position reading is elevated for a 70-year-old. Choice D is incorrect as the significant drop in blood pressure is not considered within normal limits for the patient's age.
Question 3 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 4 of 5
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:
Correct Answer: A
Rationale: The correct answer is A: Lesions that run together. Confluent lesions refer to individual lesions that merge or run together to form a larger, continuous area of involvement. This term is commonly used to describe skin lesions that have coalesced. The other choices are incorrect because B refers to lesions forming a ring shape, C describes lesions following a nerve pathway, and D implies lesions grouped closely together but not necessarily merging. Thus, A is the best choice based on the description of confluent lesions.
Question 5 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.