ATI LP 5 Health Assessment Practice Test

a nurse is caring for an older client. a nurse should recognize the client is at risk for which of the following physiological changes? - decreased gastric motility - decreased skin elasticity - increased pain threshold - increased metabolic rate - increased cardiac output

- decreased gastric motility - decreased skin elasticity - increased pain threshold

a nurse is palpating the skin of a client and documents that when picked up in a fold, the skin slowly returns to normal. what would be the next action of the nurse based on this finding? - Document a normal skin finding on the client in the chart - Assess the client for cardiovascular changes - Report the findings as positive bowel sounds - Assess the client for dehydration

Assess the client for dehydration

a nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? - Brachial - Carotid - Femoral - Popliteal

Carotid

a nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? - Explain to the client what is about to happen. - Make sure the room temperature is cool. - Provide music as an environmental distraction. - Inform the client that the provider will examine sensitive areas first.

Explain to the client what is about to happen.

a nurse is completing a client assessment for admission to the medical unit. which of the following abdominal assessment findings require further investigation by the nurse? - Symmetrical convex sphere shape - Concave umbilicus - Bilateral bowel sounds in lower quadrants - Ecchymosis

Ecchymosis

a nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? - Report of exposure to a skin irritant - Denial of pruritus - Systemic symptoms including elevated temperature - Report of generalized joint discomfort

Report of exposure to a skin irritant

a nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal? - The client's eyes do not converge when the nurse moves a finger toward the nose. - The client's eyes are black, equal in size, round and smooth - An older adult's pupils are pale and cloudy - The client's pupils dilate when looking at a near object and constrict when looking at a distant object.

The client's eyes are black, equal in size, round and smooth

When auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. the nurse should document this finding as which of the following - a systolic murmur - a third heart sound S3 - an expected heart sound - a fourth heart sounds S4

a systolic murmur

a nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in the client? - pinnae of the ears - dorsal surface of the hand - conjunctivae - dorsal surface of the foot

conjunctivae

a nurse is assessing the lungs of a client auscultates soft, low pitched sounds over the base of the lungs during inspiration. what would be the next action of the nurse based on this finding? - suspect an inflamed pleura rubbing against the chest wall - document normal breath sounds - recommend testing for pneumonia - assess for bruits

document normal breath sounds

what assessment technique would the nurse use to assess a client's chest for color, shape, or contour? - inspection - palpation - percussion - auscultation

inspection - observing

a nurse is assessing a client's bowel sounds. at which of the following points in the assessment should the nurse auscultate the client's abdomen? - after palpating the abdomen - prior to percussing the abdomen - after assessing for kidney tenderness - prior to inspecting the abdomen

prior to percussing the abdomen

a nurse is assessing a client's cardiovascular system. to palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place their fingers? - the left 2nd intercostal space - the right 2nd intercostal space - the left 5th intercostal space - the left 5th intercostal space at the midclavicular line

the left 2nd intercostal space