ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
Which of the following anatomic landmark associations is correct?
Correct Answer: A
Rationale: The correct answer is A. In tension pneumothorax, needle decompression is performed at the 2nd intercostal space in the midclavicular line to release trapped air. This location ensures proper decompression of the pleural space. Choice B is incorrect because T6 is typically the level for the lower margin of the endotracheal tube, not the insertion point. Choice C is incorrect as the sternal angle corresponds to the 2nd rib, not the 4th rib. Choice D is incorrect as the 5th intercostal space is commonly used for chest tube insertion to drain the pleural space, not for needle decompression in tension pneumothorax.
Question 2 of 5
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
Correct Answer: D
Rationale: The correct answer is D because it directly acknowledges the situation while also establishing the purpose of the conversation. By addressing Mrs. H. by name and explaining the need to ask about what happened, the nurse shows empathy, professionalism, and sets the tone for a confidential and supportive interaction. Choice A is incorrect because it lacks specificity and fails to address the immediate concerns of the patient. Choice B is incorrect as it diverts from the primary issue by commenting on the weather. Choice C is incorrect as it jumps straight into asking how the patient is without acknowledging the reason for the visit, which may not be appropriate given the circumstances.
Question 3 of 5
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ________ of the underlying tissue.
Correct Answer: C
Rationale: Percussion is used to assess the density of underlying tissue by producing sound waves and evaluating the quality of sound produced. Density refers to the compactness of tissue, which can help identify abnormalities such as fluid or air accumulation. Turgor (A) is the skin's elasticity, not assessed by percussion. Texture (B) refers to the feel of the tissue, not evaluated through percussion. Consistency (D) is the uniformity of tissue, which is not primarily assessed by percussion. Therefore, the correct answer is C as it directly relates to the purpose of percussion in assessing underlying tissue density.
Question 4 of 5
During the examination, which action by the nurse helps reduce patient anxiety?
Correct Answer: C
Rationale: The correct answer is C because offering brief teaching during the exam helps reduce patient anxiety by providing information and reassurance. This action fosters a sense of understanding and involvement, empowering the patient. Explaining findings in simple terms can alleviate confusion and fear. Maintaining a hurried demeanor (B) can increase anxiety due to perceived lack of care. Avoiding discussion (D) may lead to feelings of neglect. Using medical terminology (A) can further confuse and distress the patient, worsening anxiety.
Question 5 of 5
A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:
Correct Answer: C
Rationale: The correct answer is C: Unexplained weight loss often accompanies short-term illnesses. In this case, the patient has been treated for pneumonia for the past 6 weeks, which is a short-term illness. Weight loss in this context could be due to factors like increased metabolic rate or decreased appetite related to the illness. Choice A is incorrect because the weight loss is unexplained, not necessarily due to unhealthy eating habits. Choice B is incorrect as hypertension is not typically associated with significant weight loss. Choice D is incorrect as there is no indication in the scenario provided that the weight loss is due to a mental health dysfunction.