ATI Comprehensive physical assessment of an adult post test
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
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
A nurse is assessing a client cranial nerves. Which of the following client actions is an indication that cranial nerve one is intact
The client can identify a minty scent
A nurse is assessing a clients peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the clients 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
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 towards your nose
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the clients breathing. The nurse should identify this observation as which of the following findings?
Crackles
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
A nurse is palpating a tender area of a clients 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
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 mid clavicular line
A nurse is performing 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
A nurse is performing an abdominal assessment on a client. Over which of the following areas of the clients abdomen should the nurse attempt to ascultate active bowel sounds first?
Right lower quadrant
A nurse is performing a general client survey and find 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