ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's mental status. Which question best evaluates the patient's recent memory?
Correct Answer: B
Rationale: The correct answer is B because asking the patient what they had for breakfast this morning evaluates their recent memory. This question assesses the patient's ability to recall a specific event from the same day, testing their short-term memory. Choices A, C, and D do not focus on recent memory. Choice A tests long-term memory, choice C assesses immediate memory, and choice D evaluates remote memory. Therefore, B is the best question to evaluate recent memory.
Question 2 of 5
Which of the following findings is most concerning during a neurological assessment?
Correct Answer: D
Rationale: The correct answer is D because a positive Babinski sign in an adult indicates an abnormal response suggesting potential neurological dysfunction, specifically upper motor neuron pathology. This finding is concerning as it can indicate underlying issues such as spinal cord injury, brain tumor, or multiple sclerosis. In contrast, choices A and B are normal findings, indicating proper pupil response and equal strength, respectively. Choice C also indicates normal mental status. So, a positive Babinski sign is the most concerning because it suggests potential serious neurological issues, while the other choices are within normal parameters.
Question 3 of 5
A physical therapist evaluates a patient with adhesive capsulitis of the shoulder. Which intervention is MOST appropriate to improve range of motion?
Correct Answer: A
Rationale: The correct answer is A: Joint mobilization. Joint mobilization involves skilled passive movement techniques applied to a joint to restore motion. In adhesive capsulitis, there is restricted motion due to adhesions within the joint capsule. Joint mobilization helps break down these adhesions, improving range of motion. Electrical stimulation (B) and ultrasound therapy (C) may help with pain management but do not directly address the joint restriction. Postural training (D) may be beneficial for overall shoulder function but is not the most direct intervention for improving range of motion in adhesive capsulitis.
Question 4 of 5
Which assessment finding is most consistent with a diagnosis of arterial insufficiency?
Correct Answer: B
Rationale: The correct answer is B - Dependent rubor and cool skin. Arterial insufficiency is characterized by poor blood flow to the extremities, resulting in decreased oxygen supply and tissue damage. Dependent rubor (redness when legs are in a dependent position) and cool skin are indicative of decreased arterial blood flow. Brown discoloration (choice A) typically indicates chronic venous insufficiency. Pitting edema (choice C) is associated with venous insufficiency and heart failure. Warm, erythematous skin (choice D) is more indicative of inflammation or infection, rather than arterial insufficiency.
Question 5 of 5
During a skin assessment, the nurse observes a patient's mole and notes that it has an irregular border, varied colors, and a diameter of 8 mm. What is the appropriate action?
Correct Answer: C
Rationale: The correct answer is C: Refer the patient for further evaluation. The patient's mole exhibits characteristics associated with melanoma, such as irregular border, varied colors, and a diameter larger than 6 mm (8 mm in this case). Referring the patient for further evaluation by a dermatologist or healthcare provider specializing in skin assessments is crucial for prompt diagnosis and appropriate treatment if necessary. Options A, B, and D are incorrect because ignoring or delaying evaluation of suspicious moles can lead to potential complications or missed opportunities for early intervention in case of skin cancer.