ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 5
Which respiratory disease causes a restrictive, parenchymal pattern of illness?
Correct Answer: C
Rationale: The correct answer is C: Sarcoidosis. Sarcoidosis is a respiratory disease that causes a restrictive, parenchymal pattern of illness characterized by granulomatous inflammation in the lung tissue. This results in fibrosis and scarring, leading to reduced lung capacity and difficulty in expanding the lungs fully. Myasthenia gravis (A) is an autoimmune neuromuscular disorder affecting muscle function, not the respiratory system. Asthma (B) is an obstructive lung disease characterized by airway inflammation and bronchoconstriction, leading to airflow limitation. Ankylosing spondylitis (D) is a systemic inflammatory condition primarily affecting the spine and joints, not the lungs.
Question 2 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 3 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 4 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 5 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.