ATI RN
CNS Vital Signs Assessment Questions
Question 1 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.
Question 2 of 5
An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?
Correct Answer: D
Rationale: The correct answer is D because the presentation of a tender, reddish-blue auricle with vesicles suggests frostbite, which is caused by prolonged exposure to extreme cold. Understanding the patient's exposure to cold is crucial for proper treatment. A: Change in ability to hear is not directly related to the physical findings described. B: Recent drainage from the ear is not typically associated with the described symptoms. C: While trauma may cause similar symptoms, the presentation of vesicles is more indicative of frostbite rather than trauma.
Question 3 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 4 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 5 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.