ATI Head to toe health assess

You are performing an assessment of a client's head and neck. Which of the following findings during an assessment require notification of the provider? -Asymmetrical smile -Blood vessels visible on the periphery of the sclera -Red color of the nasal mucosa -Reports of pressure during sinus palpation

-Asymmetrical smile WHY? Asymmetrical smile or facial features can indicate the presence of a neurological disorder such as a stroke or a facial nerve paralysis. The provider should be notified of these unexpected findings.

Which of the following can be assessed from a client's general appearance? (Select all that apply.) -Body type -Gait -Blood pressure -Posture -Pupilary roaction to light -Capillary refil

-Body type WHY? A client's body type can be assessed by the general appearance of the client's weight to height. -Gait WHY? How a client moves and walks can be observed as the client enters and moves about the examination area. Limping, shuffling, weakness, tremors, use of assistive equipment, or lack of balance can be noted. -Posture WHY? A client's posture can be observed by seeing how they stand and sit, as well as if they lean or slump with abnormal posture.

You are preparing to measure a client's blood pressure manually with a sphygmomanometer. Which of the following arteries should you auscultate when using a stethoscope to listen for Korotkoff sounds? -Brachial -Coronary -Femoral -Subclavinn

-Brachial WHY? The cuff is placed around the upper part of the client's arm, with the bottom edge an inch above the brachial artery pulsation. The bell of the stethoscope is placed over the brachial artery to auscultate the Korotkoff sounds while observing the pressure reading on the sphygmomanometer.

You are examining a client's anterior chest wall. Which of the following assessment findings indicates the presence of a barrel chest? -Uneven scapulas -Costal margin of 110 -Visible pulsation at the PMI -Client sitting in a tripod position

-Costal margin of 110 WHY? The angle between the lower ribs should be less than 90°. An increased angle of the costal margin is associated with an increased AP diameter of the chest known as a barrel chest. This finding may be seen in clients who have a chronic lung disorder.

You are performing an assessment of a client's eyes. Which of the following techniques and tools should you plan to use? (Select all that apply.) -Percussion -Inspection -Palpation -Examination gloves -Penlight -Tape measure

-Inspection WHY? Inspection is a visual examination. You would use this technique when examining the eyes. -Examination gloves WHY? You should apply clean gloves before assessing the conjunctiva and sclera of the client's eyes. -Penlight WHY? A penlight is used to assess the pupillary response to light which is part of an eye examination.

Which of the following do you assess when asking questions about a client's orientation? -Level of pain -Mental state -Family medical history -Personal hygiene

-Mental state RATIONALE Why? Orientation questions are a useful strategy for nurses to assess a client's mental state during the initial general survey. These questions ensure the client understands who they are, where they are, and has a correct sense of time.

You are planning to assess the amplitude of a client's carotid pulse. Which of the following techniques should you implement when performing this examination? -Palpate one artery at a time -Apply equal bilateral pressure simultaneously -Inspect using a penlight with the client positioned supine -Apply pressure below the cricold cartilage as the client swallows

-Palpate one artery at a time WHY? Each artery should be palpated individually to prevent the disruption of blood flow to the brain.

You are preparing to assess vital signs and obtain baseline measurements during the head-to-toe assessment. Which of the following tools should you plan to use? (Select all that apply.) -Tape measure -Sphygmomanometer -Watch -Reflex hammer -Pulse oximeter

-Sphygmomanometer -Watch -Pulse oximeter

Place the steps for auscultating a male client's heart sounds in the correct order. -Position the client with head of bed elevated 30 to 45°. -Place stethoscope on second intercostal space on client's right side. -Place stethoscope on fourth intercostal space at left stermal border. -Place stethoscope on second intercostal space on client's left side -Inspect the PMI for visible pulsation. -Place stethoscope on fifth intercostal space on client's left side medial to the midclavicular line. -Auscultate apical pulse for 1 min noting rate, rhythm and amplitude.

1- Position the client with head of bed elevated 30° to 45°. 2- Inspect the PMI for visible pulsation. 3- Place stethoscope on second intercostal space on client's right side. 4- Place stethoscope on second intercostal space on client's left side. 5- Place stethoscope on fourth intercostal space at left sternal border. 6- Place stethoscope on fifth intercostal space on client's left side medial to the midclavicular line. 7- Auscultate apical pulse for 1 min noting rate, rhythm and amplitude.

You are performing an assessment of a client's abdomen. Which of the following findings should you report to the provider? -Abdominal movement during inhalation -Hyperactive audible bowel sounds -Voluntary guarding -Shiny taut skin

Shiny taut skin Glistening tight skin typically indicates the presence of free fluid in the abdominal cavity, termed ascites, and should be reported to the provider.