ATI Skills Module 3.0: Comprehensive Physical Assessment of an Adult

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. This is where you inspect and palpate for the point of maximal impulse. Also called the apical pulse station, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical pulse is not always visible but can be felt as a brief thump. This is an expected finding it should be performed when you're preparing to osculate the apical pulse.

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the clients that the Romberg test is used to assess which of the following characteristics?

Balance

A nurse is performing a respiratory assessment on a client. The nurse osculates a wet, popping sound up on inspiration of the clients breathing. The nurse should identify this observation as which of the following findings?

Crackles Crackles, sometimes called rales, are wet, popping sound created by the air 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 assessment on a client. Which of the following actions should the nurse plan to take first?

Develop a plan of care. The first action the nurse should take using the nursing process is to as/sess 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 clients foot, between the attendance of the great toe and those of the town next to it, in order to pop a check which of the following pulses?

Dorsalis pedis.

Hey 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. The nurse should inserts that your pieces at a downward angle towards their nose because this helps ensure that sounds are effectively transmitted to their eardrums.

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. The first action the nurse should take using the nursing process is to assess the clients. The nurse should begin a complete physical examination by inspecting the clients body systematically, observing for both expected and unexpected physical findings. When assessing most body systems, the recommended order is inspection, palpitation, 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. Aka "hunchback" is a curvature of the spine. Is an abnormal angular ion of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is more 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.

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. It 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 auscultaste active bowel sounds first?

Right lower quadrant. This is because the ileocecal valve is located here and is normally very active with bowel sounds. For an avg. adult expect to hear 5-30 bowel sounds per minute.

A nurse is assessing a client cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact?

The client can identify a minty sent. Cranial nerve I, the olfactory nerve, controls the sense of smell.

A nurse is performing a general client survey And finds that the client has a body mass index of 23. Which of the following should the nurse document?

The client has a BMI within the expected reference range. BMI is a measurement of an adult 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.