ATI Health Assess 2.0: Head to Toe

a nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

"Can you tell me your birthday?" Clients are typically able to state their name and birthday even when experiencing an altered mental state. Therefore, this question does not adequately screen for an alteration in orientation. "Can you tell me what month it is?" This question assesses the client's orientation to time. Disorientation due to delirium or dementia usually presents initially as confusion to time and then progresses to include place. "Can you tell me what you had for lunch yesterday?" This question assesses the client's recent memory. It does not assess for orientation. "Can you repeat the four words that I asked you to remember?" This question assesses the client's ability to form new memories. It does not assess for orientation.

a nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather?

Blood glucose meter is incorrect. Measuring a client's blood glucose is not included in a head-to-toe assessment. This tool is utilized to assess a client who is at risk for hypoglycemia and hyperglycemia. Penlight is correct. A penlight provides additional lighting to allow for close inspection. It is additionally used to assess pupillary light reflex. Stethoscope is correct. A stethoscope is used to auscultate sounds produced by the body, which can provide information regarding a client's health status. Sphygmomanometer is correct. Measuring a client's vital signs provides baseline data, which is part of the head-to-toe assessment. Sterile gloves is incorrect. The nurse should plan to gather clean gloves when anticipating contact with mucous membranes, nonintact skin, or other potentially contaminated areas.

a nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action?

Depth of pedal pitting edema is incorrect. The depth of pedal pitting edema should be assessed during a focused assessment of the cardiovascular system. If the client has edema of the hands and wrists, this should be noted when assessing the radial pulse rate. Regularity of the pulse is correct. The nurse should note the regularity of the pulse. If the pulse is irregular, the nurse should count the rate for a full minute for accuracy. Presence of a murmur is incorrect. The presence of a murmur can be detected when auscultating the apical pulse, which is performed during a focused assessment of the cardiovascular system. Presence of a bruit is incorrect. A bruit is auscultated when there is a narrowing of a blood vessel. This assessment is usually performed on the carotid arteries in an older adult client during a focused assessment of the cardiovascular system. Strength of the pulse is correct. The strength of the pulse provides information about the amount of blood that is being ejected during each contraction of the heart muscle.

a nurse is inspecting the anterior chest of a client. Which of the findings should the nurse report to the provider?

Distended veins in one breast Dilated superficial veins in one breast are an unexpected finding and should be reported to the provider. During pregnancy, it is an expected finding to have increased vasculation in both breasts. Costal margin of 85° It is expected for the angle of the rib cage to be less than 90°. PMI located to the left of the midclavicular line at the 4th intercostal space The point of maximal impulse (PMI) of the apical pulse should be located at either the 4th or 5th intercostal space, and medial to the midclavicular line. Symmetrical chest expansion during the inspiratory phase The chest wall should expand equally during inspiration.

a nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance?

During an interview about the client's health history is correct. While interviewing the client, the nurse should collect general information about the client's appearance, nutritional state, emotional status, speech, hearing, and mobility. When introducing themselves to the client is correct. During the initial introduction, the nurse should collect general information about the client's appearance, nutritional state, emotional status, speech, hearing, and mobility. Once the focused assessments have been completed is incorrect. The nurse should perform a general survey during their initial interactions with the client. During a general survey, the nurse collects information about the client's state of health and any obvious physical alterations. While collecting the client's vital signs is correct. Assessing vital signs is typically one of the first tasks performed during a head-to-toe assessment. The nurse can observe the client's appearance, nutritional state, emotional status, speech, hearing, and mobility while performing this task. During the discussion of planning for follow-up care is incorrect. The nurse should perform a general survey during the initial interactions with the client. During a general survey, the nurse collects information about the client's state of health and any obvious physical alterations.

a nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during the assessment?

Instruct the client to swallow is correct. A swallowing motion will cause the thyroid gland to move upward. While this gland is not typically visible, inspecting the neck while the client swallows can enable the detection of an enlarged thyroid gland. Apply downward pressure and ask the client to shrug their shoulders is correct. Having the client move their shoulders upward against pressure allows the nurse to evaluate the client's neck muscle strength and the function of cranial nerve XI, the spinal accessory nerve. Tell the client to open their mouth and say "ahhh" is incorrect." This action allows the nurse to inspect the rise of the soft palate and uvula, which is a function of cranial nerve X, the vagus nerve. This assessment is included in the examination of the mouth and in a neurologic examination. Test the client's ability to protrude their tongue is incorrect. Assessing a client's ability to protrude their tongue is included in the examination of the mouth and in a neurologic examination. This action is a function of cranial nerve XII, the hypoglossal nerve. Request the client move their head forward and backward and then side to side is correct. Having the client move their head forward and backward allows the nurse to evaluate the range-of-motion of the client's neck.

a nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client?

Lung sounds is correct. The nurse should plan to assess every client's pulmonary status. This includes lung sounds, respiratory effort, and skin color. Bowel sounds is correct. The nurse should plan to assess every client's bowel function. Auscultation is performed prior to palpation of the abdomen because palpation stimulates peristalsis, which can lead to an incorrect assessment of the client's baseline bowel motility. Measurement of abdominal girth is incorrect. The measurement of the abdominal girth is a specialized assessment that should be performed on clients who have an actual or potential problem that requires this action. It is not necessary to perform this assessment on all clients. Pedal pulses is correct. The nurse should plan to assess every client's cardiovascular status. This includes assessing capillary refill, pulses, and the presence of edema. Mental status is correct. The nurse should plan to assess the level of consciousness in every client to determine a baseline.

a nurse is planning to complete a physical assessment on a client. which of the following actions should the nurse plan to include?

Maintain client modesty by auscultating over the client's clothing. The nurse should always place the stethoscope directly against the client's skin when auscultating. Listening through clothing will alter the quality and type of sound. Include the nurse's interpretation when recording objective information. Documentation of objective findings should be clear, concise, and factual. They should reflect what the nurse sees, hears, feels, and smells. The documentation should not reflect the nurse's interpretation of the findings. Perform the assessment in the same order. The nurse might need to vary the order of the assessment depending on the severity of the client's manifestations. If the client is acutely ill, the nurse should first assess the body system that is most likely to present with findings outside the expected range. Use quotation marks when documenting client statements. Statements made by the client are considered subjective data. Pertinent statements should reflect the client's exact words and always be recorded within quotation marks.

a nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?

Nutritional status is correct. During the general survey, the nurse should assess the client's nutritional status. Hygiene is correct. During a general survey, the nurse should observe the client to determine if they appear clean and groomed. The nurse can additionally note the presence of body odor and if their dress is appropriate for the weather. Lung expansion is incorrect. Assessing symmetric lung expansion is performed during a focused assessment of the respiratory system. While lung expansion cannot be assessed during a general survey, the nurse can observe if the client is demonstrating difficulty breathing. Posture is correct. During a general survey, the nurse can observe the client's upright posture, including the alignment of their hips and shoulders. Range of motion is incorrect. Range-of-motion is assessed during a focused assessment of the musculoskeletal system. While range-of-motion cannot be assessed during a general survey, the nurse can observe the client's gait and general mobility.

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

Palpate client-identified areas of discomfort first. The nurse should plan to assess any identified tender areas last to minimize the client's discomfort during the examination. Begin auscultation in the left upper quadrant. Auscultation of the abdomen should begin in the right lower quadrant. This is the location of the ileocecal valve, where bowel sounds are typically present. Auscultate bowel sounds prior to palpating. Auscultation is performed prior to palpation of the abdomen because palpation stimulates peristalsis, which can lead to an incorrect assessment of the client's baseline bowel motility. Count the number of bowel sounds auscultated over 1 min. It is not necessary to count bowel sounds. Bowel sounds are irregular and occur typically 5 to 30 times over a minute.

a nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Palpate the strength of the brachial pulses. The nurse should palpate the strength of the femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally. The brachial pulse is located in the arm. Observe the client's gait as they walk across a room. The nurse should observe the client's gait when assessing their general appearance. The nurse should note if the client's movements are smooth and coordinated with the arms swinging freely, if their foot placement is accurate, and if the they can balance independently. Use a sharp pin to assess for sensation on the sole of the client's foot. Sensory nerve function should be assessed using a paper clip or cotton swab. The nurse should assess this function in an area where the skin is sensitive or thin. The skin on the bottom of the foot and the heel is thickened and might not accurately reflect nerve function. Inspect the pattern of hair distribution. An absence of hair on the lower legs can indicate the presence of inadequate circulation to the lower extremities and should be noted.

a nurse is preparing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the temporomandibular joint for pain. Clients who report jaw pain can have alterations in the temporomandibular joint. Palpating a clicking or grating in this area is an unexpected finding associated with degenerative joint disease. Palpate the mastoid area for pain. When a client reports ear pain, the nurse should palpate the outer ear and mastoid areas to determine if there is any localized area of discomfort. Increased pain with palpation of the outer ear typically indicates an external ear infection. Tenderness in the mastoid area can indicate an infection in the mastoid process located behind the ear. Inspect the nasal mucosa for redness. Clients who report congestion might have alterations in the appearance of their nasal mucosa. Redness, edema, and drainage of the nasal mucosa are common findings associated with an upper respiratory infection. A pale, swollen mucosa is often observed when a client has allergic rhinitis. Inspect the conjunctival sac for redness. Clients who report eye discomfort might have changes in the appearance of their conjunctival sac. Alterations in color, such as redness, pallor or cyanosis, and the presence of edema or lesions are unexpected findings.

a nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Position the client in prone position. The nurse should assess the posterior and lateral chest when the client is in a sitting position because this position maximizes chest expansion. If the client is unable to sit upright, they should be placed in a side-lying position to allow for inspection and auscultation of the posterior chest. Observe for the use of accessory muscles during inspiration. The nurse should observe for the presence of retractions or the use of accessory neck muscles during inspiration. The presence of these findings is associated with an airway obstruction or a large amount of collapsed alveoli causing an increased effort required to inspire. Begin auscultating at the level of C4. The nurse should begin auscultating lung sounds at the intercostal space below C7. Reposition the stethoscope downward at 4 inch (10 cm) intervals. The nurse should reposition the stethoscope at 2 inch (5 cm) intervals, in a zig-zag pattern, when auscultating breath sounds.

a nurse is assessing a client's vital signs. while counting the number of respirations. which of the following information should the nurse collect?

Characteristics of the respirations While counting the respirations, the nurse should observe the effort the client is using and the depth and regularity of the breaths. Symmetric expansion of the chest walls The nurse should assess for symmetrical expansion by placing both hands on the client's posterolateral chest walls during a focused assessment of the chest and lungs. Shape and alignment of the rib cage Assessing the anteroposterior diameter and configuration of the chest wall should be performed during a focused assessment of the chest and lungs. Intensity of tactile fremitus The nurse should assess for symmetry in the intensity of vibration on the posterior chest wall while the client is repeating specified words during a focused assessment of the chest and lungs.

a nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take?

Inspect the condition of each fingernail is correct. The nurse should inspect a client's fingernails for the shape, texture, and color. Changes to fingernails can occur with a variety of chronic illnesses. Apply a pulse oximeter to a finger is incorrect. A pulse oximeter provides information about a client's atrial oxygen saturation levels. Compare the amplitude of the radial pulses bilaterally is correct. The nurse should palpate the radial pulses simultaneously to note any differences in the rate, rhythm, or strength of the pulses. Evaluate the blood pressure in an upper extremity is incorrect. A client's blood pressure provides information about their cardiovascular status. Palpate the shoulder, elbow, wrist and finger joints is correct. The nurse should plan to palpate each joint in the upper extremities to note the presence of any warmth, swelling, or discomfort.