ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?
Correct Answer: D
Rationale: The correct answer is D: The purpose of the tubes is to decrease the pressure and allow for drainage. Tympanostomy tubes are inserted into the eardrum to allow for drainage of fluid from the middle ear, decreasing pressure and preventing recurrent ear infections. This is important for the child's hearing and overall health. A: The tubes are not placed in the inner ear. They are placed in the eardrum to assist in drainage. B: Tympanostomy tubes are not used for sensorineural loss, but rather for conditions like recurrent ear infections or fluid buildup in the middle ear. C: The tubes are not permanently inserted during a surgical procedure. They are typically temporary and will eventually fall out on their own.
Question 2 of 5
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
Correct Answer: B
Rationale: The correct answer is B: A bifid uvula may occur in some Native-American groups. A bifid uvula refers to a split or forked uvula, which is a variation of normal anatomy and can be seen in certain populations, including some Native-American groups. This condition is usually benign and does not typically cause any health issues. It is important for healthcare providers to be aware of such variations to avoid unnecessary concern or intervention. Explanation for incorrect options: A: This condition is not a cleft palate, which is a more severe congenital condition involving a gap in the roof of the mouth. C: There is no indication that the bifid uvula is due to an injury or that it should be reported to authorities. D: "Palatinus" is not a term commonly used to describe a bifid uvula, and the statement about its frequency in Native Americans is not supported by evidence.
Question 3 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 4 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 5 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.