ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ________ of the underlying tissue.
Correct Answer: C
Rationale: Percussion is used to assess the density of underlying tissue by producing sound waves and evaluating the quality of sound produced. Density refers to the compactness of tissue, which can help identify abnormalities such as fluid or air accumulation. Turgor (A) is the skin's elasticity, not assessed by percussion. Texture (B) refers to the feel of the tissue, not evaluated through percussion. Consistency (D) is the uniformity of tissue, which is not primarily assessed by percussion. Therefore, the correct answer is C as it directly relates to the purpose of percussion in assessing underlying tissue density.
Question 2 of 5
A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:
Correct Answer: C
Rationale: The correct answer is C: Unexplained weight loss often accompanies short-term illnesses. In this case, the patient has been treated for pneumonia for the past 6 weeks, which is a short-term illness. Weight loss in this context could be due to factors like increased metabolic rate or decreased appetite related to the illness. Choice A is incorrect because the weight loss is unexplained, not necessarily due to unhealthy eating habits. Choice B is incorrect as hypertension is not typically associated with significant weight loss. Choice D is incorrect as there is no indication in the scenario provided that the weight loss is due to a mental health dysfunction.
Question 3 of 5
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
Correct Answer: B
Rationale: The correct answer is B: The change in blood pressure readings is called orthostatic hypotension. This is because the blood pressure drop of 50/30 mm Hg between lying and standing positions meets the criteria for orthostatic hypotension (a drop of 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing). Choice A is incorrect as these readings indicate orthostatic hypotension, not just a normal response to position changes. Choice C is incorrect because the lying position reading is elevated for a 70-year-old. Choice D is incorrect as the significant drop in blood pressure is not considered within normal limits for the patient's age.
Question 4 of 5
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
Correct Answer: D
Rationale: The correct answer is D: Melanocytes. Melanocytes are responsible for producing melanin, the pigment that gives hair its color. As individuals age, the number of functioning melanocytes decreases, leading to a loss of pigment in the hair, resulting in gray or white hair. Metrocytes (A), Fungacytes (B), and Phagocytes (C) are not involved in hair pigmentation, making them incorrect choices in this context.
Question 5 of 5
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:
Correct Answer: A
Rationale: The correct answer is A: Lesions that run together. Confluent lesions refer to individual lesions that merge or run together to form a larger, continuous area of involvement. This term is commonly used to describe skin lesions that have coalesced. The other choices are incorrect because B refers to lesions forming a ring shape, C describes lesions following a nerve pathway, and D implies lesions grouped closely together but not necessarily merging. Thus, A is the best choice based on the description of confluent lesions.