ATI RN
Neurological Vital Signs Assessment Questions
Question 1 of 5
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
Correct Answer: A
Rationale: The correct answer is A: Consider this a normal finding. The liver typically produces a dull sound upon percussion due to its solid nature. This is considered a normal finding as the liver is a solid organ. Palpation for an underlying mass (Choice B) is not necessary based solely on the dull percussion sound. Repositioning hands and percussing again (Choice C) is unlikely to change the result. Referring the patient for additional treatment (Choice D) is premature without further assessment. Therefore, A is the correct choice based on the expected percussion sound over the liver.
Question 2 of 5
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
Correct Answer: B
Rationale: The correct answer is B because leaving the thermometer in place for 3 to 4 minutes allows for an accurate reading of oral temperature. This duration ensures the mercury in the thermometer reaches equilibrium with the body temperature. Choice A is incorrect as waiting 30 minutes after ingesting hot or iced liquids is unnecessary for assessing oral temperature. Choice C is incorrect as placing the thermometer in front of the tongue and asking the patient to close their lips may not provide an accurate reading. Choice D is incorrect as shaking the thermometer down before taking the temperature is not necessary and can introduce errors in the reading.
Question 3 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 4 of 5
A 22-year-old woman comes to the clinic because of severe sunburn and states, 'I was out in the sun for just a couple of minutes.' The nurse begins a medication review with her, paying special attention to which medication class?
Correct Answer: B
Rationale: The correct answer is B: Tetracyclines for acne. Tetracyclines are known to cause photosensitivity, increasing the risk of sunburn with minimal sun exposure. The nurse should review this medication class as the patient's severe sunburn may be a side effect. Nonsteroidal anti-inflammatory drugs (Choice A) are not directly related to photosensitivity. Proton pump inhibitors (Choice C) are used for reducing stomach acid, not linked to sunburn. Thyroid replacement hormone (Choice D) does not typically cause sunburn as a side effect. Therefore, the focus on tetracyclines is crucial in this scenario.
Question 5 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.