ATI Physical Assessment (Adult)

You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging?

kyphosis - Hunchback curvature of the spine, abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. Most common in older adults and tends to increase with aging. Also common with people who have had vertebral fractures.

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

RLQ, Right lower quadrant - To the right of the umbilicus in the RLQ is the ileocecal valve. This is where the small intestine connects to the large intestine and it is normally very active with bowel sounds. Many nurses begin listening here for that reason. For the average adult, you'll hear five to thirty bowel sounds per minute.

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as

crackles - Crackles, which are sometimes called rales, are wet popping sounds created by air moving through liquid or by collapsed alveoli snapping on open inspiration. They are most common at the end of respiration.

What is your primary goal in performing a comprehensive physical assessment?

to develop a plan of care - Remember the nursing process: assessment, diagnosis, planning, implementation, evaluation.

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following findings is considered normal?

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 PMI/apical pulsation.

While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient's

Balance - The most common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of you, with her feet together, toes pointed forward, and her hands at her sides. While you extend your hands so that one is on either side of the patient, ask her to close her eyes. Watch to see how well she can maintain balance in that position. A minimum swaying is normal, but if the patient sways more than a couple of inches, stop the test and document that the patient demonstrated difficulty maintaining balance on Romberg testing.

When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient's foot between the extensor tendons of the great toe and those of the toes next to it. Which pulse are you palpating?

Dorsalis pedis - In the LE, the most common pulse tested is the dorsalis pedis pulse, found on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.

As part of your general patient survey, you find that your patient has a body mass index (BMI) of 23. From this finding, you can conclude that your patient

has a body mass index within normal limits - BMI is a measurement of an adult's body fat based on height and weight. Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a normal amount of body fat. A patient with a BMI below 18.5 is considered underweight; a patient with a BMI of 25 or above is considered overweight; and one with a BMI of 30 or above is considered obese.

While examining your patient's head and face, you determine that cranial nerve I is intact when the patient follows your instructions and successfully

identifies a minty scent - CN I, the olfactory nerve, controls the sense of smell. To test this nerve's function, as the patient to identify a nonirritating aroma, such as mint or coffee.

When using and maintaining your stethoscope, it is important to

insert the earpieces at an angle toward your nose - Angling the earpieces toward your nose helps ensure that sounds are effectively transmitted to your eardrums.

When performing a complete, head-to-toe physical examination, which physical-assessment technique should you perform first?

inspection - inspection is the process of observation. You will first inspect the body systematically observing for normal as well as abnormal physical signs. Most body systems follow the recommended order of inspection, palpation, percussion, and auscultation. Abdominal assessment is an exception.

While performing an abdominal assessment, you place your fingertips over the patient's painful area and gradually increase pressure, then quickly release it. The patient reports increased pain on release of pressure, so you document that your patient has positive

rebound tenderness - This procedure elicits rebound tenderness - an increase in pain when deep palpation over a tender area is released. Rebound tenderness is in the RLQ at McBurney's point (one third the distance from the anterior iliac crest to the umbilicus) and is sign of acute appendicitis.