ATI RN
CNS Vital Signs Assessment Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
The nurse is assessing a patient's mental status. Which question best evaluates the patient's recent memory?
Correct Answer: B
Rationale: The correct answer is B because asking the patient what they had for breakfast this morning evaluates their recent memory. This question assesses the patient's ability to recall a specific event from the same day, testing their short-term memory. Choices A, C, and D do not focus on recent memory. Choice A tests long-term memory, choice C assesses immediate memory, and choice D evaluates remote memory. Therefore, B is the best question to evaluate recent memory.