ATI: Comprehensive Physical Assessment of an Adult

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." Explanation: 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.

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. Explanation: 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 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 Explanation: The nurse should explain that the Romberg test is the most common test of balance.

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 Explanation: 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.

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

Inspection Explanation: 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 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 Explanation: 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.

Other than detecting physical abnormalities, what benefits are there to perform a complete physical assessment?

Physical assessment data are the cornerstone of holistic client care. You will not only assess, document and report deviations in health status but also base clinical decisions on your findings. During the exam, you have an opportunity to establish a therapeutic relationship, first by respecting the client's privacy, and then by performing assessment techniques proficiently. While using various exam maneuvers, you will ask the client relevant questions about past medical history, current condition, and related clinical findings. This nurse-client interaction during the hands-on physical assessment is the perfect time for health promotion and education.

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 Explanation: 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.

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 Explanation: 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 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. Explanation: 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 body mass index (BMI) of 23. Which of the following should the nurse document?

The client has a BMI within the expected reference range. Explanation: 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.

general

considerations