ATI Introduction to Health Assessment Test

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which step of the nursing process should the nurse perform first?

Assessment The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing a client, and observing a client.

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which ethical principal is the client using?

Autonomy Autonomy involves the client's right to make decisions about their care, including the right to refuse treatment if they choose. This ethical principle refers to a client's freedom.

A nurse is preparing to irrigate the client's leg wound. Which pieces id personal protection equipment should the nurse wear while performing this task?

Goggles Gloves Gown Goggles - The nurse should wear goggles or a face shield in case there is a threat of any bodily fluids splashing during wound care. Gloves - The nurse should don gloves when providing hands-on care. The nurse should change gloves when either the task is completed or upon soiling. Gown - The nurse should don a gown to prevent their clothes from becoming soiled if they were to come into contact with infected material, blood, or bodily fluids.

A nurse is assisting a client with ambulating around the nurses' station. Which step of the nursing process is the nurse performing?

Implementation During the implementation step, the nurse carries out the interventions developed in the plan of care, which will assist the nurse and other members of the health care team to monitor the client's progress. Implementation is when the nurse puts the plan of care into action.

A nurse has just received report on a newly admitted clement who reports abdominal tenderness in the lower right quadrant. What is the first step the nurse should perform during the abdominal assessment?

Inspection Using the nursing process, the nurse should first inspect the client's abdomen and observe for symmetry between the right and the left side of the body. The nurse should note the presence of contours and any abnormalities with the skin, rashes, deformities, or masses.

The nurse is preparing to assess a newly admitted client. Which pieces of equipment does the nurse need to begin the inspection part of the physical examination?

Penlight Tape measure Tongue depressor Penlight - The nurse should use a penlight to inspect the client's pupils and test for pupillary reflexes during the inspection part of the physical examination. Tape measure - The nurse should use a tape measure to measure the size of the wounds, bruissing, or other abnormalities of the skin during the inspection part of the physical examination. Tongue depressor - The nurse should use a tongue depressor to view the client's uvula and posterior soft palate during the inspection part of the physical examination.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which action should the nurse take to display empathy towards the client?

Put themselves in the client's situation to understand the client's anxiety. When the nurse expresses empathy, the nurse reflects an understanding of the client's feelings and feels the importance of the client's communication. This is a therapeutic communication technique.

A nurse is completing documentation in a client's medical record. Which action should the nurse take?

Record the client's most recent assessment results. The nurse should include factual, accurate, and objective information

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with the effectiveness with the client during the initial assessment process?

Request assistance from an interpreter during the assessment

A nurse is preparing to perform palpation on a client during a physical assessment. Which finding is the nurse assessing during palpation?

Skin temperature, moisture, and abnormalities. The nurse can make judgments about the findings of the skin, underlying tissue, muscle, and bones by palpating the skin for temperature, moisture, texture, and other abnormalities.

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this pet of the assessment?

Stethoscope The nurse will need a stethoscope to be able to listen to the sounds of the client's body.

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which is the type of data the nurse is collecting?

Subjective Subjective data includes feelings and concerns from the client's point of view. The reason why the client sought medical care is usually considered subjective data. This type of data, along with objective data, provides the nurse with information that will be reported to the provider.

A nurse is preparing to perform a physical examination on a client. Which intervention should the nurse perform to ensure client privacy?

Do not expose any more of the client's body than required at a time. The nurse should provide physical privacy by only exposing the section of the client's body needed at the time for proper assessment. The action helps the client feel less vulnerable.

A nurse is performing a pre-admission assessment in a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Maintain a fair distance between self and client. The nurse should maintain personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which action should the nurse take?

Palpate the tender areas of the abdomen last The client reported abdominal tenderness. So the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client