ATI RN
Neurological Vital Signs Assessment Questions
Question 1 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 2 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.
Question 3 of 5
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
Correct Answer: B
Rationale: The correct answer is B: A bifid uvula may occur in some Native-American groups. A bifid uvula refers to a split or forked uvula, which is a variation of normal anatomy and can be seen in certain populations, including some Native-American groups. This condition is usually benign and does not typically cause any health issues. It is important for healthcare providers to be aware of such variations to avoid unnecessary concern or intervention. Explanation for incorrect options: A: This condition is not a cleft palate, which is a more severe congenital condition involving a gap in the roof of the mouth. C: There is no indication that the bifid uvula is due to an injury or that it should be reported to authorities. D: "Palatinus" is not a term commonly used to describe a bifid uvula, and the statement about its frequency in Native Americans is not supported by evidence.
Question 4 of 5
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
Correct Answer: C
Rationale: The correct answer is C because bronchovesicular breath sounds in the peripheral lung fields are an expected finding in a 4-year-old child. This is due to the normal anatomy and physiology of a child's respiratory system at that age. Bronchovesicular breath sounds are commonly heard in children and are a combination of bronchial and vesicular sounds. These sounds are normal in children up to the age of 5 and are typically heard in the peripheral lung fields. Choice A is incorrect because crepitus palpated at the costochondral junctions is not an expected finding in a 4-year-old child's respiratory assessment. Crepitus may indicate air or gas under the skin and is not a normal finding in a respiratory assessment. Choice B is incorrect because no diaphragmatic excursion due to decreased inspiratory volume is not a typical finding in a 4-year-old child. Children of this age should have adequate diaphragmatic excursion, and a lack of it may indicate respiratory
Question 5 of 5
During an annual examination, a girl states that she is concerned about her development. She asks the nurse when she will get breasts. In obtaining a health history, the nurse should ascertain which of the following? The age that:
Correct Answer: A
Rationale: The correct answer is A: The girl began to develop breasts. This is crucial to determine her stage of puberty. Breast development typically starts before other secondary sexual characteristics, making it a key indicator. Knowing the age of breast development helps assess if she is within the normal range or needs further evaluation. B: Her mother developed breasts - irrelevant to the girl's current development. C: She began to develop pubic hair - secondary sexual characteristic but not as indicative as breast development. D: She began to develop axillary hair - less reliable marker of puberty compared to breast development.