ATI Introduction to Health Assessment Test

A nurse has performed pre-operative 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 ethical principal is the client using?

Autonomy

A nurse is assisting a client with ambulating around the nurses' station. Which step of the nursing process is the nurse performing?

Implementation

A nurse is performing a pre-admission assessment in 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?

Maintain a fair distance between self and client

The nurse is preparing to assess a newly admitted client. Which pieces of equipment does the nurse need to begin the inspection part of the physical examination?

Penlight Tape measure Tongue depressor

A nurse is completing documentation in a client's medical record. Which action should the nurse take?

Record the client's most recent assessment results

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 the effectiveness with the client during the initial assessment process?

Request assistance from an interpreter during the assessment

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

Skin temperature, moisture, and abnormalities

A nurse is preparing to irrigate the client's leg wound. Which pieces id personal protection equipment should the nurse wear while performing this task?

Goggles N95 mask Gloves Gown Surgical cap

A nurse has just received report on a newly admitted clement who reports abdominal tenderness in the lower right quadrant. What is the first step the nurse should perform during the abdominal assessment?

Inspection

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

Assessment

A nurse is preparing to perform a physical examination on a client. Which intervention 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 performing a physical assessment of a client who has reported abdominal tenderness. Which action should the nurse take?

Palpate the tender areas of the abdomen last The cleint relorted abdominal tenderness. So rhe nurse should palpate tender areas last because tense muscles make the assessment mkre difficult for the client

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 action should the nurse take to display empathy towards the client?

Put themselves in the client's situation to understand the client's anxiety.

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

Stethoscope

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which is the type of data the nurse is collecting?

Subjective data