ATI RN
CNS Vital Signs Assessment Questions
Question 1 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 2 of 5
The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
Correct Answer: B
Rationale: Step-by-step rationale for choice B (Decreased mobility of the thorax) as the correct answer: 1. With aging, the rib cage becomes less flexible, leading to decreased thoracic mobility. 2. This decrease in thoracic mobility is a normal finding in older adults due to changes in the musculoskeletal system. 3. Assessing for decreased thoracic mobility is important as it can impact respiratory function and overall health. Summary: A: Increased thoracic expansion is not a normal finding in older adults as aging typically results in decreased flexibility. C: Decreased anteroposterior diameter may occur in certain conditions but is not a consistent normal finding in older adults. D: Bronchovesicular breath sounds throughout the lungs are not specific to assessing the respiratory system in older adults.
Question 3 of 5
A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D because it provides reassurance based on the typical age range for breast development in girls, which is between 8 and 10 years old. By stating this, the nurse acknowledges the girl's concerns and normalizes her experience. Option A is not as specific and may not address the girl's worries directly. Option B personalizes the response, which may not be helpful in this situation. Option C focuses on menstruation, which is not directly related to breast development and may cause unnecessary anxiety. In summary, option D is the best response as it provides accurate information and reassurance tailored to the girl's concerns.
Question 4 of 5
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
Correct Answer: D
Rationale: The correct answer is D. When a woman slowly lifts her arms above her head during a breast examination, it allows for better visualization and detection of any nipple or skin retraction. This position stretches the breast tissue and skin, making any abnormalities more apparent. Additionally, observing for any lag or retraction in movement while the arms are raised can help identify any potential issues. Choice A is incorrect because bending over and touching her toes does not provide the necessary positioning to properly assess for nipple and skin retraction. Choice B is incorrect because lying down on the left side may not provide the same level of stretching and visibility as lifting the arms above the head. Choice C is incorrect because shifting from a supine position to a standing position may not provide the optimal angle for assessing nipple and skin retraction.
Question 5 of 5
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:
Correct Answer: B
Rationale: The correct answer is B. Listening with the bell of the stethoscope allows the nurse to assess for bruits, abnormal sounds indicating turbulent blood flow in carotid arteries, which could indicate potential blockages or narrowing. Palpating the artery in the upper one third of the neck (A) is not recommended as it could potentially dislodge plaque and cause a stroke. Simultaneously palpating both arteries (C) is not necessary for this assessment. Instructing the patient to take slow deep breaths (D) is not relevant to assessing the carotid arteries for bruits.