ATI: Comprehensive Physical Assessment of an Adult

Which of the following statements demonstrates understanding of cultural competence in physical assessment?

"I ask the client several questions during the general survey to determine their cultural preferences."

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 toward your nose" The nurse should insert the earpieces at a downward angle toward their nose because this helps ensure that sounds are effectively transmitted to their eardrums.

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

Which of the following questions should you ask when first meeting the client? (Select all that apply.)

A. "Can you tell me your name?" B. "Do you know what day it is?" C. "Do you know where you are?" D. "What caused you to come to the hospital?"

Which of the following elements should a nurse assess during a general survey? (Select all that apply.) A. Speech B. Hygiene C. System review D. Indications of distress E. Body movements F. Affect/mood

All of them

Which of the following assessment techniques by the nurse is correct?

Auscultate the four quadrants of the abdomen before percussing and palpating this area

Which of the following factors should you assess to evaluate the client's risk for falls and injury? (Select all that apply.)

Current medications, orthostatic blood pressures, muscle strength and symmetry, gait and use of assistive devices

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 tendons of the great toe and of those of the toe next to it, in order to palpate which of the following pulses?

Dorsalis pedis To palpate the dorsalis pedis, the nurse should place their fingertips on the top of the client's foot, between the extensor tendons of the great toe and those of the toe next to it. The dorsalis pedis is the most common pulse tested in the lower extremities.

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 client. The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation.

Tangential lighting

Lighting set to a low angle relative to a surface. It highlights protrusions by casting a shadow and small movements by flickering light.

When planning to assess the client, which of the following actions should you take to prevent activity intolerance?

Perform the assessment at the same time that you assist with the client's bath This shows respect for the need to conserve the client's energy by performing a portion of the assessment during another intervention

Bruit

Pulsing, blowing sound produced by turbulent flow.

A nurse is palpating a tender area of a client's 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 The nurse should document that the client is experiencing rebound tenderness, which 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 auscultate active bowel sounds first?

Right lower quadrant Evidence-based practice indicates that the first area the nurse should auscultate for active bowel sounds is over the right lower quadrant of the client's abdomen. The right lower quadrant is located to the right of the umbilicus and contains the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to 30 bowel sounds per minute.

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

The client can identify a minty scent. Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee.

Penlight

Used for better visualization when you examine body orifices (such as the mouth) or in skins folds where you need extra illumination.

Cotton ball

Used to test sensation to light touch on the face during cranial-nerve testing and on the lower back, trunk, and extremities as part of the neurologic exam. Compare sensation bilaterally.

You enter the client's room and find the client in bed with their eyes closed. Which of the following actions should you take?

Wake the client by calling out the client's name in a calm, quiet voice. This option demonstrates the technique for waking the client so that you can properly assess their status.

Tuning fork

a two-pronged, fork-like instrument that vibrates when struck; used to test hearing, especially bone conduction

Atelectasis

absence of breath sounds in the bases of the lower lobes of the lung due to collapse alveoli

Pneumothorax

accumulation of air or gas in the pleural space causing the lung to collapse

Crackles

also known as rales, high pitched crackling and popping sound while breathing

Rhonchi

coarse, low-pitched, rumbling sound while breathing

Edema

excessive fluid accumulation within the interstitial or intracellular spaces

Bronchial breath sounds

heard anteriorly over the trachea, you should hear a loud, high-pitched, hollow sound

Vesicular breath sounds

heard over most of the lung tissue, you should hear soft, fine, breezy, low-pitched sounds

Bronchovesicular breath

heard over the mainstem bronchi, which are relatively large-diameter airways, you should hear medium-pitched and quieter sounds

Wheezing

high pitched whistling sound while breathing

Stridor

high-pitched musical sound most commonly heard during inspiration

Speculum

instrument that exposes the interior of a passage or cavity of the body by enlarging its opening

Auscultation

listening to the sounds of the body

Pallor

paleness; a decrease or absence of skin coloration

Thrill

palpable vibration on the caused by turbulent blood flow

Erythema

redness of the skin caused by dilation of the superficial capillaries

Friction rub

scratching or squeaking sound heard over the lung fields that indicates inflammation of the pleura

Pericardial friction rub

scratching or squeaking sound heard over the precordium that indicates inflammation of the pericardial lining

Tongue depressor

used to hold down a client's tongue while you visualize the throat or to check the gag reflex

Using a stethoscope

1. Place the earpieces in your ears, making sure that they are directed toward your nose. 2. Gently rub or tap on the diaphragm to ensure that the stethoscope's head is rotated correctly. 3. Apply firm pressure on the diaphragm using your index and middle fingers when placing it on the client's skin. The diaphragm is for listening to high-pitched sounds. Ensure that nothing rubs against the tubing because that will generate distracting sounds. 4. Rotate the head to the bell for low-pitched sounds. Use light pressure but ensure that the entire rubber ring around the bell is in contact with the client's skin.

You assess the client for possible indications of a stroke. Which of the following techniques should be used to evaluate facial symmetry?

Assess cranial nerve VII by asking the client to smile and puff out cheeks

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 The nurse should explain that the Romberg test is the most common test of balance.

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

Crackles Crackles, sometimes called rales, are wet, popping sounds created by air moving 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 physical 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 assess the client and develop a plan of care. The nursing process follows the steps of assessment, analysis, planning, implementation, and evaluation.

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

Which of the following actions should you take when assessing the client's respiratory function?

Reassessing lung sounds after asking the client to cough Reassessing the lung sounds can determine the effectiveness of the client's cough since coughing could result in expelling mucous from the air passages

Heart murmurs

Sounds produced by turbulent flow of blood from the heart. They are described in terms of their intensity, location, timing, duration, pitch, quality, and transmission.

A nurse is performing a general client survey and finds 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. BMI is a measurement of an adult's 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. Therefore, the nurse should document that the client has a BMI within the expected reference range for a client who has a BMI of 23.

Otoscope

instrument for examining the ear