ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
When performing a physical assessment, the first technique the nurse will always use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. Inspection is the first technique used in a physical assessment as it involves observing the patient's overall appearance, skin color, posture, and any obvious abnormalities. This step provides valuable initial information before moving on to other techniques. Palpation, percussion, and auscultation are typically used after inspection to gather more detailed data. Palpation involves touching and feeling for abnormalities, percussion involves tapping to assess underlying structures, and auscultation involves listening to internal sounds. These techniques are important in a comprehensive assessment, but inspection is the initial step to guide the assessment process.
Question 2 of 5
A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes is a risk factor for peripheral vascular disease?
Correct Answer: B
Rationale: The correct answer is B: Coronary artery disease. Peripheral vascular disease shares similar risk factors with coronary artery disease, such as atherosclerosis. Atherosclerosis is a major contributing factor to both conditions, leading to narrowing and blockage of blood vessels. This increases the risk of reduced blood flow to various organs and tissues, causing symptoms of peripheral vascular disease. The other choices, A: Gastroesophageal reflux disease, C: Migraine headaches, and D: Osteoarthritis, do not have direct associations with peripheral vascular disease or share common risk factors with it. For example, GERD is related to the gastrointestinal system, migraines are neurological, and osteoarthritis affects the joints, making them unrelated to the pathophysiology of peripheral vascular disease.
Question 3 of 5
The nurse has received a status report on the following patients admitted with head injuries, which patient should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D because an unresponsive and dilated pupil (10 mm) can indicate a serious condition like brain herniation, which requires immediate medical attention to prevent further damage. Assessing this patient first is crucial to ensure prompt intervention. - Choice A: A linear skull fracture may require observation but does not indicate an immediate life-threatening condition. - Choice B: Clear leakage from the nose after cranial surgery suggests a CSF leak, which is important but not as urgent as an unresponsive pupil. - Choice C: Losing consciousness for a few minutes after a fall could indicate a concussion, which is concerning but less urgent than a dilated unresponsive pupil.
Question 4 of 5
The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:
Correct Answer: B
Rationale: The correct answer is B because right-sided hemiparesis involves weakness on the right side of the body, including the face and tongue. This condition is not characterized by complete bilateral paralysis (A), the ability to walk independently (C, D), or the loss of movement in just the right arm (C, D). In right-sided hemiparesis, the weakness affects more than just the arm and may impact various parts of the body on the right side.
Question 5 of 5
The nurse is assessing a patient's gait. Which finding indicates a normal gait?
Correct Answer: D
Rationale: The correct answer is D because a symmetrical stride length indicates a normal gait. When both legs move in a coordinated manner and cover equal distances, it suggests proper balance and coordination. Absent arm swing (A) can indicate a gait abnormality. A narrow base of support (B) can lead to instability. Unequal step lengths (C) can also point to an abnormal gait pattern. In summary, a symmetrical stride length is crucial for an individual to maintain balance and walk efficiently.