ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?
Correct Answer: D
Rationale: The correct answer is D because the eustachian tube helps equalize air pressure on both sides of the tympanic membrane. This is important for maintaining proper function of the middle ear. The other choices are incorrect because: A) Cerumen is produced by the ceruminous glands, not the eustachian tube. B) The eustachian tube normally remains closed and only opens during swallowing, yawning, or sneezing to equalize pressure. C) The eustachian tube connects the middle ear to the nasopharynx, not the outer ear.
Question 2 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 3 of 5
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
Correct Answer: C
Rationale: The correct answer is C: Rheumatic fever. Strep throat is caused by group A Streptococcus bacteria. If left untreated, the bacteria can lead to an autoimmune response, causing rheumatic fever. This condition can result in inflammation and damage to the heart, joints, and other tissues. Rubella (A) is a viral infection unrelated to strep throat. Leukoplakia (B) is a precancerous condition of the mouth. Scarlet fever (D) is a complication of strep throat but is characterized by a rash and not the autoimmune response seen in rheumatic fever.
Question 4 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 5 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.