ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
Which of the following is a contraindication for spinal traction?
Correct Answer: C
Rationale: The correct answer is C: Osteopenia. Osteopenia is a contraindication for spinal traction due to decreased bone density, which increases the risk of fractures during traction. Bursitis (A) is not a contraindication, as it affects the soft tissues around the joints. Cervical radiculopathy (B) can benefit from spinal traction to relieve nerve compression. Muscle spasm (D) is not a contraindication but can actually be a reason for using traction to alleviate muscle tension.
Question 2 of 5
You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely?
Correct Answer: B
Rationale: The correct answer is B: Lymph node. A lymph node is typically mobile in both up-and-down and side-to-side directions due to its structure and function in the body's immune system. Lymph nodes are small, bean-shaped structures that filter lymph fluid and help fight infections. The mobility is important for their role in filtering and monitoring the lymphatic system. Choice A (Cancer) is less likely as cancerous masses are typically fixed and do not move easily. Choice C (Deep scar) is unlikely as scars are not typically mobile masses. Choice D (Muscle) is also unlikely as muscles are not typically felt as mobile masses in the context described.
Question 3 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 4 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 5 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.