ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
Correct Answer: A
Rationale: The correct answer is A because in infants, it is recommended to measure respirations first, followed by pulse and temperature. Infants have irregular breathing patterns, so measuring respirations first allows for the most accurate reading. Pulse and temperature can be affected by handling the infant, so they should be measured after respirations. Choice B is incorrect because vital signs in infants are typically measured at the same frequency as in adults, unless there are specific concerns or conditions. Choice C is incorrect because involving the parent in the procedure and encouraging the infant to handle the equipment may not be appropriate or necessary for measuring vital signs accurately. Choice D is incorrect because it is not necessary to perform a physical examination before measuring vital signs in an infant. It is important to follow the standard sequence of measuring respirations, then pulse, and temperature for accurate readings.
Question 2 of 5
A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
Correct Answer: B
Rationale: The correct answer is B: Impetigo. Impetigo presents with moist, thin-roofed vesicles with a thin erythematous base, commonly found on the face and buttocks. The vesicles rupture, forming honey-colored crusts. The history of a new babysitter suggests exposure to skin infections. Eczema (choice A) presents with dry, scaly patches. Herpes zoster (choice C) presents with grouped vesicles along a dermatome. Diaper dermatitis (choice D) presents with erythema and scaling in the diaper area. The key features in this case match impetigo, making it the correct choice.
Question 3 of 5
The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?
Correct Answer: C
Rationale: The correct answer is C: VIII (Vestibulocochlear nerve). This cranial nerve is responsible for conducting nerve impulses to the brain from the organ of Corti, which is located in the cochlea of the inner ear. The vestibulocochlear nerve is specifically involved in transmitting auditory information to the brain. A: CN I (Olfactory nerve) is responsible for the sense of smell, not related to the organ of Corti. B: CN III (Oculomotor nerve) controls eye movements. D: CN XI (Accessory nerve) is responsible for controlling muscles of the neck and shoulders, not related to auditory functions. In summary, choice C is correct because the Vestibulocochlear nerve is specifically responsible for transmitting auditory information from the organ of Corti to the brain, while the other choices are not related to this specific function.
Question 4 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 5 of 5
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?
Correct Answer: C
Rationale: Rationale: Choice C is correct because bluish lips and a dark line along the gingival margin are normal pigmentation variations seen in individuals with darker skin tones, especially in Black patients. This is known as racial pigmentation and does not indicate any health concern. Choices A, B, and D are incorrect as they are not relevant to this specific physical finding and may lead to unnecessary testing or interventions. Checking hemoglobin, assessing for oxygen supply, and inquiring about carbon monoxide exposure are not indicated based on the racial pigmentation seen in this patient.