Nursing 1201 - Mod 7 : Physical Assessment ATI

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?

"Insert the earpieces at a downward angle toward your nose"

A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation?

"i have a cough"

A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives?

-Parents -Siblings -Grandparents

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39° C (102° F). Which of the following other vital signs should the nurse expect?

An elevated pulse rate

A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. What action should the nurse take?

Ask the client for additional information regarding the management of their diabetes

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

Assessment

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

A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics?

Balance

A nurse is evaluation a 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?

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings?

Crackles

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?

Develop a plan of care

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

Do not expose any more of the client's body than required at a time.

A nurse is preparing to irrigate a client's leg wound. Which of the following personal protective equipment should the nurse wear while performing this task?

Goggles Gown Gloves

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 on lower legs

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform dung the abdominal assessment?

Inspection

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first?

Inspection

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging?

Kyphosis

A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health?

Limited access to a pharmacy

A nurse is performing a preadmission assessment on 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?

Maintaining an arm's length between self and client

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?

Nutritional Status Hygiene Posture

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

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?

Observe the client's chest movements while appearing to assess their pulse

A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question?

Open-ended question

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?

Over the 5th intercostal space at the left midclavicular line

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

Palpate the tender areas of the client's abdomen last.

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?

Place the probe in the posterior lingual pocket to the midline

A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading?

Pull the pinna back and upward gently

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?

Pulse pressure

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

Skin temperature, moisture, or unexpected findings

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

Stethoscope

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?

Tape measure Penlight Tongue depressor

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact?

The client can identify a minty scent

A nurse is performing a general client survey and finds that the client has a body mass index (BMI) of 23. Which of the following should the nurse document?

The client has a BMI within the expected reference range

The nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse?

The client's abdomen is soft and nondistended

A nurse is planning to complete a physical assessment of a client. Which of the following actions should the nurse plan to take?

Use quotation marks when documenting client statements.

A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask?

What pronouns do you use?

A nurse has performed preoperative 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 of the following ethical principles is the client using?

Autonomy

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

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses?

Dorsalis Pedis

A nurse is assessing a client's respiration. Which of the following actions should the nurse take?

Elevate the head of the client's bed 45° to 60°

A nurse is assisting a client with ambulating around the nurse's station. Which of the following steps of the nursing process is the nurse performing?

Implementation

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration?

Observe the degree of chest-wall movement during inspiration and expiration

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

Palpate the mastoid area for pain

A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview?

Provide an opportunity for the client to ask questions

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 effective communication with the client during the initial assessment process?

Request assistance from an interpreter during the assessment

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?

Respirations 30/min

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?

Right lower quadrant

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 of the following actions should the nurse take to display empathy towards the client?

Show interest in the client's feelings by acknowledging that they are upset.

A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when i wake up." Which of the following types of data is the nurse documenting?

Subjective

A nurse is conducting a health history interview with a client. Which of the following is true of a directive interview technique?

This technique consists of mostly closed-ended questions

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

When the semilunar valves close

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?

"Would you like information on smoking cessation?"

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

Characteristics of reparations

A nurse is conducting a health history interview. Which of the following type of information is the nurse gathering when using the acronym "OLD CARTS"?

Information about the client's presenting problem

A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take?

Insert the probe about 2.5 cm into the client's anus

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?

It might not follow with a 5th sound

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

Use a cuff of the appropriate size for the client

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

-Regularity of the pulse -Strength of pulse

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document?

Rebound tenderness

A nurse is collecting information about a client's spirituality using the FICA Spiritual History Tool. Based on this tool, which of the following information should the nurse gather?

-Does the client identify spiritual or religious beliefs that are of importance to them? -What impact do the client's spiritual beliefs have on their health care decision making? -Are there any spiritual or religious practices that should be included in the client's care? -Is there a spiritual or religious group that the client identifies as having importance in their life

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?

-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 planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take?

-Gather supplies to take notes -Select a position 2-4 feet away from the client -Ensure face-to-face contact is at eye level

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment?

-If the client is experiencing any abuse or human trafficking -The environment in which the client resides -The client's use of substances -Client's ability to perform activities associated with daily living

A nurse is assessing a client's upper extremities. Which of the following actions should the nurse take?

-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 assessing a client's neck. Which of the following actions should the nurse ask the client to perform during this assessment?

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

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following should the nurse plan to assess for every client?

-Lung sounds -Bowel sounds -Pedal pulses -Mental status

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use?

-Prescription medications take for recreational use -Determination of when the client last had an alcoholic drink

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply.)

-The client has a BMI of 35 -The client is reporting a stuffy nose -the client is taking digoxin for an irregular heart rate -The client had a mastectomy 2 years ago

A nurse is collecting a health history from a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Speak directly to the client throughout the interview