ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
Which of the following findings is most concerning during a neurological assessment?
Correct Answer: D
Rationale: The correct answer is D because a positive Babinski sign in an adult indicates an abnormal response suggesting potential neurological dysfunction, specifically upper motor neuron pathology. This finding is concerning as it can indicate underlying issues such as spinal cord injury, brain tumor, or multiple sclerosis. In contrast, choices A and B are normal findings, indicating proper pupil response and equal strength, respectively. Choice C also indicates normal mental status. So, a positive Babinski sign is the most concerning because it suggests potential serious neurological issues, while the other choices are within normal parameters.
Question 2 of 5
Which assessment finding is most consistent with a diagnosis of arterial insufficiency?
Correct Answer: B
Rationale: The correct answer is B - Dependent rubor and cool skin. Arterial insufficiency is characterized by poor blood flow to the extremities, resulting in decreased oxygen supply and tissue damage. Dependent rubor (redness when legs are in a dependent position) and cool skin are indicative of decreased arterial blood flow. Brown discoloration (choice A) typically indicates chronic venous insufficiency. Pitting edema (choice C) is associated with venous insufficiency and heart failure. Warm, erythematous skin (choice D) is more indicative of inflammation or infection, rather than arterial insufficiency.
Question 3 of 5
During a skin assessment, the nurse observes a patient's mole and notes that it has an irregular border, varied colors, and a diameter of 8 mm. What is the appropriate action?
Correct Answer: C
Rationale: The correct answer is C: Refer the patient for further evaluation. The patient's mole exhibits characteristics associated with melanoma, such as irregular border, varied colors, and a diameter larger than 6 mm (8 mm in this case). Referring the patient for further evaluation by a dermatologist or healthcare provider specializing in skin assessments is crucial for prompt diagnosis and appropriate treatment if necessary. Options A, B, and D are incorrect because ignoring or delaying evaluation of suspicious moles can lead to potential complications or missed opportunities for early intervention in case of skin cancer.
Question 4 of 5
The nurse is auscultating the lungs and hears low-pitched, soft sounds over the peripheral lung fields. How should this finding be documented?
Correct Answer: C
Rationale: The correct answer is C: Vesicular breath sounds. These are low-pitched, soft sounds heard over the peripheral lung fields during normal breathing. This finding should be documented as vesicular breath sounds because they are expected in healthy individuals. Choice A: Bronchial breath sounds are high-pitched and loud, heard over the trachea and large airways, not the peripheral lung fields. Choice B: Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, typically heard over the mainstem bronchi, not the peripheral lung fields. Choice D: Adventitious breath sounds refer to abnormal lung sounds like crackles or wheezes, not the soft, low-pitched sounds described in the scenario.
Question 5 of 5
Which physical assessment finding is most indicative of chronic hypoxia?
Correct Answer: B
Rationale: The correct answer is B: Clubbing of the fingers. Clubbing is a sign of chronic hypoxia due to prolonged oxygen deprivation, leading to changes in the nails and fingertips. This occurs in conditions like chronic lung disease. Barrel chest (choice A) is typically seen in emphysema due to lung hyperinflation. Use of accessory muscles (choice C) and intercostal retractions (choice D) are signs of acute respiratory distress, not chronic hypoxia.