physical assessment final exam - ATI questions

A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (select all that apply) A. parents B. siblings C. aunts & uncles D. cousins E. grandparents

A,B,E

A nurse is preparing to perform a skin assessment on a client which of the following tools should the nurse plan to use?

penlight

a nurse is preparing to assess a newly admitted client which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination?

penlight, tape measure, tongue depressor

nurse is inspecting the fingernails of an older adult client which of the following findings should the nurse report to the provider?

spongy nail base

A nurse is performing auscultation during a client's physical assessment which of the following tools should the nurse use for this part of the assessment?

stethoscope

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temp of the client? A. Axillary B. Temporal C. Tympanic D. Rectal

D

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect?

Defined reddened area of the sclera

A nurse is caring for a client who has stage one pressure injury which of the following information should the nurse include when documenting the characteristics of the wound select all that apply

Location of the pressure injury Size of the injury in CM Integrity of the skin surrounding the wound

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture, and abnormalities

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye?

Transparent layer that covers the iris & the pupi

A nurse is providing teaching to a client who boards extremely dry skin which of the following intervention should the nurse recommend?

apply an alcohol free lotion

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider?

yellow discoloration of the palms

a nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? A. document client data B. provide an opportunity for client to ask questions C. explain the reason for the insurance D. greet client with an introduction

B

a nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? A. limited access to convenience foods B. a park available within walking distance from a client's residence C. limited access to a pharmacy D. a neighborhood population that has a high rate of obesity & smoking

C

A nurse is performing a focused assessment on a client who reports having difficulty swallowing & a continuous headache. The nurse should identify that these findings can indicate which of the following conditions?

Central Nervous system disorder

A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? A. leading question B. closed ended question C. direct question D. open ended question

D

A nurse is a evaluating assessment findings of a client's skin the nurse should identify which of the following findings is associated with the possible infection?

vesicles

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect?

white patches on the tongue

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect?

yellow sclera

A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory range? A. The client has been a chronic smoker for 10 years B. The client takes a narcotic pain medication for chronic pain C. The client reports anxiety due to being in the hospital D. The client has a history of anemia

B

A nurse is completing documentation in a client's medical record. which of the following actions should the nurse take?

Record the client's most recent assessment results.

a nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states " i have changed my mind; i do not want to have this surgery" which of the following ethical principles is the client using

autonomy

A nurse is performing a physical assessment of a client who has reported abdominal tenderness which of the following actions should the nurse take?

palpate the tender areas of the abdomen last

A nurse is performing a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions?

thyroid disorder

nurse is examining the texture of an older adult clients skin. which of the following findings should the nurse report to the provider?

velvety skin

A nurse is collecting a healthy history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take? A. speak directly to the client throughout the interview B. ensure the interpreter is positioned behind the client for privacy C. ask the interpreter to summarize a group of questions for the client D. use accurate medical terminology when gathering information

A

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe the involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus

A

A nurse is conducting a health history interview with a client. which of the following is accurate about a directive interview technique? A. this technique consists of mostly closed ended questions B. this technique enables the client to control the pace of the interview C. This technique is used to gather general information about a client's condition D. this technique is effective for determining a client's emotional responses

A

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (select all that apply) A. prescription medications taken for recreational purposes B. determination of when the client last had an alcoholic drink C. frequency of consumption of over the counter(OTC) medications D. adverse reactions to medications & environmental substances E. highest level of schooling completed

A,B

A nurse is collecting information about a client's spirituality using the FICA spiritual History tool. Based on this tool, which of the following information should the nurse gather? (select all that apply) A. does the client identify spiritual or religious beliefs that are of importance to them? B. what impact does the client's spiritual or religious beliefs have on their health care decision making? C. are there any spiritual or religious practices that should be included when planning the clients care? D. what is the address of the client's identified religious or spiritual gathering place? E. is there a spiritual or religious group that the client identifies as having an importance in their life?

A,B,C,E

A nurse is caring for a client who is reporting pain as a 4 on a scale 0-10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply) A. The client reports that the pain has been present for 4 years B. The client reports never feeling total relief from pain C. The client's pain can be attributed to an acute injury or illness D. The client reports that the pain is recurring and does not always originate in the same location E. The client describes the pain as transient

A,B,D

a nurse is conducting a health history interview. Which of the following questions should the nurse ask when gathering information about a client's cardiac and peripheral vascular system?(select all that apply) A. "have you experienced any chest pain, tightness or discomfort?" B. "have you had any changes in your appetite or food intolerances?" C. "have you noticed any swelling in your hands, feet, or ankles?" D. "Do you feel short of breath during the day or while sleeping?" E. "when did you last have a screening test for tuberculosis?"

A,C,D

A nurse is planning to conduct a health history interview with a client. which of the following actions should the nurse plan to take? (select all that apply) A. gather supplies to take notes B. review the client's medical record at the conclusion of the interview C. conduct the interview in an open area such as the receptions area or hallway D. select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview E. ensure a face to face contact is at eye level

A,D,E

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions. (Move the steps into the box on the right, placing them in the selected order of performance.)

Apply gloves, instruct the client to look up, place thumbs below each of the client's lower eyelids, gently pull the client's skin down, and inspect the color & condition of the conjunctiva & sclera, noting any color change, swelling, drainage, or lesions.

a nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? A. "How does your family feel about your gender identity?" B. "What pronouns do you use?" C. "when did you transition?" D. "Are you planning to ever have surgery to change your biological sex?"

B

a nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take? A. asses the client's blood glucose level B. ask the client for additional information regarding the management of their diabetes C. encourage the client to join a diabetic support group D. provide education for the client on the management of diabetes

B

A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? A. "You are worried about the amount that you smoke, right?" B. "Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea?" C. "Would you like any information on smoking cessation?" D. "Why do you think that you are smoking so much?"

C

A nurse is documenting vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? A. Tmp 95, client is hypothermic B. Pulse rate indicated tachy C. Oxygen saturation 96% on O2 2L/min via nasal cannula D. BP 108/65 mm Hg in left arm

C

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? A. Have an informal conversation with the client before beginning observation of the client B. Complete all focused assessments prior to formulating thoughts regarding the client's general health status C. Engage in active listening with the client and allow the client to express concerns early in the assessment process D. Sit on the client's bedside with them to have close contact and maintain eye contact when possible

C

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Measure the client's shoe heel height with a tape measure and deduct this amount B. Have the client gently lift their chin and look toward the ceiling C. Ensure the client's feet are in contact with the wall or measuring pole D. Skip the height measurement if the client cannot stand

C

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? A. The client is sitting in a relaxed posture B. The client asks for a tissue and uses it to wipe away an occasional tear C. The client tells the nurse that visits from their friends and family make them smile D. The client reports they feel sad and lonely most of the time

D

a nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? A. "I had a rash from poison ivy on my arms last week, but it's gone now" B. "I wear a hearing aid" C. "I had a negative tuberculosis screening test last month" D. "I have a cough"

D

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following action

Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses, firmly press upward on the ridge, ask the client if they detect any tenderness or pain, position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses, & apply firm, upward pressure and ask the client if they detect any tenderness or pain.

a nurse in the emergency department has received report on a child who has a laceration to the right calf which of the following steps of the nursing process should the nurse perform first

assessment

A nurse is planning to take an orthostatic bp from a client who has a syncope. In what order should the nurse take the following steps? A. Assist client to stand and obtain their bp B. Keep the cuff in place and assist the client to a seated position C. Take the clients bp in the supine position D. Place the client in a supine possition and allow them to rest E. Take the clients blood pressure in a seated position

d,c,b,e,a

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply)

dirty clothing, unexplained physical injuries, malnourished appearance

A nurse is performing a head & neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?

encounter

A nurse is assisting a client with ambulating around the nurses' station. which of the following steps of the nursing process is the nurse performing

implementation

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration and which of the formula location should the nurse perform the assessment?

inferior to the collar bone

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant which of the following is the first step the nurse should perform during the abdominal assessment?

inspection

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take?

keep the clients bed in the lowest position

a nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication which of the following actions demonstrates the use of a nonverbal communication technique by the nurse

maintain a fair distance between self and client

A nurse is having difficulty obtaining a pulse ox reading from a client. The nurse should identify which of the following factors can interfere with obtaining a pulse ox reading?

recent scan with contrast dye

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?

request assistance from an interpreter during the assessment

A nurse is performing a head & neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading fine print. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?

review of systems

A nurse is examining a lesion on a client's back which of the following characteristics should the nurse identify as a possible indication of a Malignant skin lesion?

size of a pencil eraser

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110 bpm. The nurse should identify this as which of the following unexpected findings?

tachycardia

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the clients right leg or arms how should the nurse interpret this finding?

the client might have a blood clot

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect bp? (Select all that apply) A. Time of day B. Obesity C. Diuretic med D. Height E. Smoking

A,B,C,E

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply) A. Current med list B. Past medical history C. Use of assistive devices D. Height and weight E. Behavior and mood

C,D,E

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect?

beefy red tongue

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of the following findings indicates the client might have a skull fracture?

bloody drainage

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (Select all that apply.)

"Are you experiencing any difficulty breathing?", "How long has the lump been on your neck?", "Is the lump causing you discomfort?", & "Are you having difficulty swallowing

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? A. Tachypnea B. Bradypnea C. Apnea D. Hyperventilation

A

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (select all that apply) A. the reason that the client is seeking health care B. if the client is experiencing abuse or human trafficking C. the environment in which the client resides D. the client's use of substances E. client's ability to perform activities associated with daily living

B,C,D,E

A nurse is assessing an older client's mouth. The nurse should identify that which of the following is an expected variation for this client?

Darkening of the mucosa.

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?

Do not expose any more of the client's body than required at a time

A nurse is caring for a client who had a suspected stroke. Which of the following actions should they take? (Select all)

Make the client NPO, assess the client's orientation, & obtain the client's vital signs

A nurse is a nurse is teaching a young adult about risk factors for developing Melanoma which of the following client state may indicates an understanding of the teaching?

The blistering sunburns I had as a child increase my risk for melanoma as an adults

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations performed on a regular basis? (Select all that apply.)

Vision screening every year, dental exam every 6 months

A nurse is preparing to irrigate a client's leg wound what PPE should the nurse wear?

goggles, gown, gloves

A nurse is assessing a clients skin color which of the following area should the nurse check to determine the presence of pallor?

mucous membranes

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure which of the following actions should the nurse take to display empathy towards the client

put themselves in the clients situation to understand the clients anxiety

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (Select all that apply.)

"Have you had trouble hearing?", "Do you ever lose your balance?", "Have you ever used hearing aids?", & "Do you have ringing in your ears?"

nurse is collecting data from a client about their skin and nails which of the following statements by the client should the nurse identify as needing further assessment?

I noticed that my fingernails have changed recently.

A nurse is providing teaching to a client and move forward acting on their face and chest which of the following client statement indicates an understanding of the teaching?

I should wash the areas frequently with warm water and soap

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include?

Limit elevation of the head of the bed to 30 Degree or less.

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply.)

Oval white patches in the client's hair, a lesion on the client's scalp, protrusion of the client's head, and edema around the client's eyes.

A nurse is assessing a client skin color which of the following finding report to the nurse airport through the provider?

Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nailbeds

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?

pale mucosa

a nurse is performing an assessment on a client the client states" i have a dry cough every morning when i wake up" which of the following is the type of date the nurse is collecting?

subjective