ATI: Head-to-Toe Test

A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather? (Select all that apply.)

Penlight is correct. A penlight provides additional lighting to allow for close inspection. It is additionally used to assess pupillary light reflex. Stethoscope is correct. A stethoscope is used to auscultate sounds produced by the body, which can provide information regarding a client's health status. Sphygmomanometer is correct. Measuring a client's vital signs provides baseline data, which is part of the head-to-toe assessment.

A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider?

Distended veins in one breast Rationale: Dilated superficial veins in one breast are an unexpected finding and should be reported to the provider. During pregnancy, it is an expected finding to have increased vasculation in both breasts.

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should be nurse inspect when performing a general survey of the client? (Select all that apply.)

Nutritional status Hygiene Posture

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action? (Select all that apply.)

Regularity of the pulse Strength of the pulse

a nurse is planning to complete a physical assessment of client. which of the following actions should the nurse plan to include?

use quotation marks when documenting client statements (subjective)

A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

"Can you tell me what month it is?" This question assesses the client's orientation to time. Disorientation due to delirium or dementia usually presents initially as confusion to time and then progresses to include place.

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance? (Select all that apply.)

During an interview about the client's health history When introducing themselves to the client While collecting the client's vital signs

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? (Select all that apply.)

Instruct the client to swallow. Apply downward pressure and ask the client to shrug their shoulders. Request the client move their head forward and backward and then side to side.

A nurse is assessing a client's vital signs. While counting the number of respirations, which of the following information should the nurse collect?

Characteristics of the respirations (depth & regularity)

A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Observe for the use of accessory muscles during inspiration. Rationale: The nurse should observe for the presence of retractions or the use of accessory neck muscles during inspiration. The presence of these findings is associated with an airway obstruction or a large amount of collapsed alveoli causing an increased effort required to inspire.

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

Auscultate bowel sounds prior to palpating. Rationale: Auscultation is performed prior to palpation of the abdomen because palpation stimulates peristalsis, which can lead to an incorrect assessment of the client's baseline bowel motility.

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take? (Select all that apply.)

Inspect the condition of each fingernail. Compare the amplitude of the radial pulses bilaterally. Palpate the shoulder, elbow, wrist, and finger joints.

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Inspect the pattern of hair distribution. Rationale: An absence of hair on the lower legs can indicate the presence of inadequate circulation to the lower extremities and should be noted.

A nurse is performing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the mastoid area for pain. When a client reports ear pain, the nurse should palpate the outer ear and mastoid areas to determine if there is any localized area of discomfort. Increased pain with palpation of the outer ear typically indicates an external ear infection. Tenderness in the mastoid area can indicate an infection in the mastoid process located behind the ear.

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client? (Select all that apply.)

lung sounds bowel sounds pedal pulses (cardiovascular status) mental status