The nurse is performing a neurological assessment and notes that the patient has a positive Babinski sign. What does this finding indicate?

Correct Answer: B

Rationale: The positive Babinski sign indicates upper motor neuron dysfunction. When the sole of the foot is stroked, the big toe extends upward instead of curling down. This suggests damage to the corticospinal tract, characteristic of upper motor neuron lesions. Choices A, C, and D are incorrect because a positive Babinski sign is not a normal finding in adults, not related to peripheral neuropathy, and not indicative of cerebellar dysfunction.

Correct Answer: B

Rationale: The correct answer is B, respiratory distress. When a patient is using accessory muscles to breathe, it indicates increased effort to maintain adequate ventilation, a hallmark of respiratory distress. This can be due to various conditions such as asthma, pneumonia, or acute respiratory distress syndrome. Accessory muscle use is a compensatory mechanism to help increase airflow in the presence of respiratory compromise. Choices A, C, and D are incorrect because the use of accessory muscles is not indicative of a normal breathing pattern, pulmonary embolism, or COPD specifically. It is important to recognize and address respiratory distress promptly to prevent further complications.

Correct Answer: A

Rationale: The correct answer is A: Atrial fibrillation. A rapid, irregular pulse is a classic hallmark of atrial fibrillation, which is a common arrhythmia characterized by disorganized electrical activity in the atria. This leads to an irregular and often rapid ventricular response. Sinus arrhythmia (B) is a normal variation in heart rate associated with breathing and is typically regular. Ventricular tachycardia (C) is a life-threatening arrhythmia with a regular, fast heartbeat originating in the ventricles. Bradycardia (D) is a slow heart rate, which is the opposite of what is described in the question.

Correct Answer: A

Rationale: RN (Registered Nurse), is correct because upon admission, a comprehensive assessment, including vital signs, is typically performed by an RN due to their advanced training and scope of practice. RNs interpret data, identify abnormalities, and develop care plans, making them the most appropriate initial evaluator. LPN (Licensed Practical Nurse), assists with care but often works under RN supervision with a narrower scope. PCT (Patient Care Technician), and CNA (Certified Nursing Assistant), perform basic tasks like taking vital signs but lack the RNs authority to assess and act on findings independently upon admission. Hospital protocols prioritize RNs for initial assessments to ensure accuracy and timely intervention, especially in critical cases. Thus, A is the best choice, reflecting professional standards and patient safety priorities.

Correct Answer: D

Rationale: Normal vital signs vary by age. For a 4-month-old, a temperature of 38.1°C (100.5°F) is within the normal range of 37.1°C to 38.1°C (98.7°F to 100.5°F), making A correct. A 3-year-olds normal blood pressure is around 89/46 mmHg; 118/80 is elevated, so B is incorrect. A 9-year-olds temperature of 39°C (102.2°F) exceeds the normal range of 36.8°C to 37.8°C (98.2°F to 100°F), so C is incorrect. An adolescents pulse of 70 beats/min fits the normal range of 55 to 105, making D correct. Adults have a respiratory rate of 12 to 20 breaths/min, and older adults have a pulse of 40 to 100 beats/min, but these arent options here. Since this is a multiple-choice question with one answer listed as correct, D is the focus, supported by its alignment with age-specific norms.