final exam ati
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. the protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
Flatus
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles?
Herpes simplex and varicella
A nurse is performing an integumentary assessment for a group of clients? Which of the following findings should the nurse recognize as requiring immediate intervention?
cyanosis
A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following activities?
fastening or zipping closures on the back while dressing
a nurse is assessing an adult's client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take?
insert the speculums slightly down and forward, make sure the speculum does not touch the ear canal, use the light to visualize they tympanic membrane in a cone shape
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?
16/min
A nurse in a provider's office is preforming a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?
Dorsal surface
A nurse, who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items?
A familiar object the nurse places in the hand
A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?
Ask the client if they are having pain
A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next?
Auscultation
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V?
Clench your teeth and tell me when you feel a touch
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate?
Closure of the mitral valve and apical heart rate
A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination? which of the following findings should the nurse expect?
Concave lumbar spine posteriorly, muscles slightly larger on the dominant
a nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions in the priority for measuring vital signs for this client?
Do not measure the client's temperature rectally
A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?
Dorsal surface
A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding?
Loss of adipose tissue, dehydration, diminished skin elasticity
A nurse is instructing a group of assistive personnel in measure a client's respiratory rate. Which of the following guidelines should the nurse include?
Place the client in semi-fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle
a nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance?
Romberg test and heal-to-toe walk
a nurse is collecting data for a client's comprehensive physical examination of an older adult client. Which of the following skills of the physical examination process should the nurse perform next?
auscultation
A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
Tympany and high-pitched clicks
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client?
Use a mix of open- and closed- ended questions, reduce environmental noise, perform the general survey before the examination.
a nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age?
plans to allow plenty of time for position changes, make sure as the client to take their time answering questions, tell the client to take their time answering questions, invite the client to use the bathroom before beginning the examination.
A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey?
posture, skin lesions, and speech
A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect?
resonance and bronchovesticular sounds
A nurse is caring for a client who asks what their Snellen eye test results eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make?
Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical should the nurse expect?
capillary refill less than 3 seconds, thick skin on the soles of the feet, numerous macules on the face darker than the surrounding skin color
A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take?
obtain culture specimens before initiating antimicrobials, encourage the client to rest and limit activity, and assist the client with oral hygiene frequently.
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following should the nurse expect?
palpating the thyroid in the lower half of the neck, feeling the thyroid ascend as the client swallows, and finding symmetric extension off the trachea on both sides of the midline
A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age?
plan to allow plenty of time for position changes, make sure the client has any essential sensory aids in place, tell the client to take their time answering questions, invite the client to use the bathroom before beginning the examination.
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery? The nurse should test which of the following?
skin color, edema, skin temperature
A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
slower light touch sensation, some vision and hearing decline, slower fine finger movement, and some short-term memory decline
A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect?
tooth loss, glare intolerance, thickened eardrums
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client?
use a mix of open and closed ended question, reduce environment noise, and perform the general survey before the examination
