ATI ADULT HEAD TO TOE ASSESSMENT

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 pules? a. Posterior tibial b. Popliteal c. Dorsalis pedis d. Femoral

C. Dorsalis pedis To palpate the dorsalis pedis, the nurse should place their fingertips on the top of the client's foot, between the extensor tendons of the great toe and those of the toe next to it. The dorsalis pedis is the most common pulse tested in the lower extremities.

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact? a. The client can stick their tongue out. b. The client can smile symmetrically. c. The client can hear whispered words. d. The client can identify a minty scent.

D) The client can identify a minty scent. Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee.

A nurse is performing a general client survey and finds that the client has a BMI of 23. Which of the following should the nurse document? A) The client has no nutritional issues or deficits. B) The client is at high risk for obesity-related health problems. C) The client will need a referral to a dietitian. D) The client has a BMI within the expected reference range

D) The client has a BMI within the expected reference range. BMI is a measurement of an adult's body fat based on height and weight. The expected reference range for a BMI is between 18.5 and 24.9, which indicates a normal body weight. Therefore, the nurse should document that the client has a BMI within the expected reference range for a client who has a BMI of 23.

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? a. Gait b. Hearing c. Vision d. Balance

D. Balance The nurse should explain that the Romberg test is the most common test of balance. *Hearing can be evaluated in a number of ways, such as with the Weber test. The Romberg test does not assess the client's hearing. *Distance vision is typically assessed with a Snellen chart. The Romberg test does not assess the client's vision.

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 Evidence-based practice indicates that the first area the nurse should auscultate for active bowel sounds is over the right lower quadrant of the client's abdomen. The right lower quadrant is located to the right of the umbilicus and contains the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to 30 bowel sounds per minute.

A nurse was 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? a. Crackles b. Stridor c. Wheezes d. Friction rub

A) Crackles Crackles, sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration of breathing. *Stridor is a high-pitched sound typically generated when a larger airway is blocked by a foreign body, severe inflammation, or a mass. *Wheezes are continuous squeaking sounds that can be high-pitched, which is common in asthma, or low-pitched with an almost snoring quality. Low-pitched wheezes are sometimes called rhonchi. Mild wheezing is often limited to the expiratory phase of respiration, while more severe wheezing can be heard throughout the respiratory cycle. *Friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle and does not clear with coughing. It can result from the pleural membranes covering the lungs and the lining of the thoracic cavity becoming inflamed.

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? a. Document accurate data b. Develop a plan of care c. Validate previous data d. Evaluate outcomes of care

B) Develop a plan of care The first action the nurse should take using the nursing process is to assess the client and develop a plan of care. The nursing process follows the steps of assessment, analysis, planning, implementation, and evaluation.

A nurse is performing a complete head-to-toe assessment for a client. Which of the following physical assessment techniques should the nurse perform first? a. Auscultation b. Inspection c. Percussion d. Palpation

B. Inspection The first action the nurse should take using the nursing process is to assess the client. The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation.

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A. A continuous sensation of vibration felt over the second and third left intercostal spaces. B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum. C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. D. A whooshing or swishing sound over the second intercostal space along the left sternal border.

C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should be performed when you are preparing to auscultate the apical pulse.

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? a. "Insert the earpieces at a downward angle toward your nose." b. "Use the diaphragm to listen to low-pitched sounds." c. "Drape the stethoscope over your neck when not in use." d. "Clean the stethoscope by immersing it in soapy water."

A) "Insert the earpieces at a downward angle toward your nose." The nurse should insert the earpieces at a downward angle toward their nose because this helps ensure that sounds are effectively transmitted to their eardrums. *The nurse should not immerse the stethoscope in any liquid. If the stethoscope needs to be disinfected, the nurse should wipe it with a 70% isopropyl alcohol solution. For routine cleaning, the nurse should wipe the stethoscope with soapy water, but not immerse it. *The nurse should keep the tubing away from their body because polyvinylchloride (PVC) tubing stiffens when exposed to the lipids found in human skin.

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? a. Lordosis b. Kyphosis c. Ankylosis d. Scoliosis

B) Kyphosis Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older clients who have had vertebral fractures.

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? a. Borborygmi b. Rebound tenderness c. Tympany d. Abdominal guarding

B) Rebound tenderness The nurse should document that the client is experiencing rebound tenderness, which is an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.