ATI Questions

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply) A. Protrusion of the client's mastoid bone B. A lesion on the client's scalp C. Oval white patches in the client's hair D. Edema around the client's eyes E. Protrusions on the client's head.

B, C, D, and E

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? (Select all that apply) A. The pain from my car accident 2 months ago will not go away B. The pain isn't always in the same place C. I still have pain since the surgery last month, but it is getting better. D. The pain has been off and on for about a year now E. I have had this pain for 9 months

B, D, and E

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading? A. Hypertension B. Fever C. Recent scan with contrast dye D. Thin, brittle nails

C. Recent scan with contrast dye Rationale: The dye can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is assessing a client's mouth. The nurse should identify that which of the following is an expected finding? A. Yellowing of the hard palate B. Red spots on the hard palate C. White patches on the tongue D. Large vein on the ventral surface of the tongue

D. Large vein on the ventral surface of the tongue

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply) -Penlight -Tape measure -Doppler -Tongue depressor -ECG monitor

Penlight, tape measure and tongue depressor

A nurse is caring for a client with a suspected stroke. Which of the following should the nurse take? (Select all that apply.) A. Obtain vital signs B. Assess muscle strength C. Assess orientation D. Make the client NPO E. Assess for strabismus

A, B, C, and D

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply) A. Time of day B. Obesity C. Smoking D. Diuretic medication E. Height

A, B, C, and D Rationale: Time of day- Blood pressure will increase during the day and begin to decrease in the late afternoon. Obesity- Increases risk for hypertension Diuretic medication- Decreased blood pressure due to the reduction of sodium and water by the kidneys. Smoking- Vasoconstriction of blood vessels occurs when a person smokes, causing an increase in blood pressure.

A nurse is collecting information about a client's family health history. The nurse should plan to collect information about the health of which of the following client relatives? (Select all that apply) A. Parents B. Siblings C. Aunts and uncles D. Cousins E. Grandparents

A, B, and E

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? (Select all that apply) A. Use of assistive devices B. Height and weight C. Current medication list D. Past medical history E. Behavior and mood

A, B, and E

A nurse is performing an eye assessment of an older adult client and identifies a corneal ulceration. Which of the following conditions most likely contributed to this finding? A. Entropion B. Dry eye C. Arcus senilis D. Ectropion

A. Entropion Rationale: Entropion is an inversion of the lower eyelid that can lead to corneal ulceration from the friction of eyelashes. Dry eye- common finding due to an age-related changes in the tear ducts, resulting in a burning, stinging, or gritty feeling in the eye. Arcus senilis- white ring around the cornea of an older adult's eye resulting from fat deposits. Ectropion- an eversion of the lower eyelid that can cause issues with inadequate drainage of tears.

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus

A. Fasciculation Rationale: A client who has fasciculation will exhibit continuous twitching of a muscle when the muscle is at rest. Spasticity- has an increase in muscle tonicity. Attempting to passively extend a joint will result in increased resistance. Tic- Exhibit involuntary, repetitive movement of a muscle group, such as a wink or facial grimace. Myoclonus- exhibit a sudden jerking of a muscle, such as with hiccups or the jerk of an arm when falling asleep.

A nurse is inspecting the sinuses of a client who has allergies. Which of the following should the nurse expect? A. Pale mucosa B. Bright red mucosa C. Green discharge D. Yellow discharge

A. Pale mucosa Rationale: the nurse should identify that a client who has allergies can have pale mucosa, as well as clear discharge. Bright red mucosa- indicates upper respiratory infection Green discharge- Indicates an infection of the sinuses Yellow discharge- Infection of the sinuses

A nurse is assessing the mouth of a client who has vitamin B12 insufficiency. Which of the following findings should the nurse expect? A. White patches on the tongue B. Bleeding of the gums C. Beefy red tongue D. Petechiae of the hard palate

C. Beefy red tongue Rationale: White patches on the tongue- candidiasis, oral infection known as thrush Bleeding of the gums- gingivitis Petechiae of the hard palate- indicate an infection

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Deduct the client's shoe height from the measurement B. Have the client gently lift their chin and look toward the ceiling C. Ensure the client's feet are in contact with the wall or measuring pole D. Pull up the measuring pole and extend the headpiece after the client steps on the scale.

C. Ensure the client's feet are in contact with the wall or measuring pole Rationale: The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? A. Use the soft end of a cotton swab over the client's abdomen B. Auscultate the tender areas of the client's abdomen through clothing C. Palpate the tender areas of the client's abdomen last D. Use deep palpation when assessing the client's abdomen

C. Palpate the tender areas of the client's abdomen last. Rationale: The nurse should palpate the tender areas of the abdomen last to avoid client discomfort throughout the rest of the examination. When assessing the abdomen, the nurse should inspect and auscultate prior to palpation to avoid altering the bowel sounds.

A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? A. You are worried about the amount that you smoke, right? B. Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea? C. Would you like any information on smoking cessation? D. Why do you think that you are smoking so much?

C. Would you like any information on smoking cessation? Rationale: This question empowers the client to make their own decisions regarding their health care without implying judgement.

A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse obtain the most accurate core body temperature of the client? A. Axillary B. Temporal C. Tympanic D. Rectal

D. Rectal Rationale: Rectal temperature are considered the most accurate method for obtaining a client's core body temperature.

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply) -Goggles -Surgical cap -Gloves -Gown -N95 mask

Goggles, gloves, and gown