ATI Health Assessment Comprehensive Review

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Daily weight

A nurse is caring for a client in the emergency who, 2 hr earlier, served the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization

A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect?

Painful lesions following a nerve pathway

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Palpates the abdomen prior to performing auscultation

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

Passage of flatus

A nurse is completing an admission assessment on an adolescent client who is vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

Peanut butter and jelly sandwich

A nurse is assessing a client who has ataxia. which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform Romberg's test. Nurse should check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed.

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the the nurse take first?

Perform a bladder scan

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Tugging on the affected ear lobe

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

"How do you handle stress?"

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's current weight-bearing status

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following sings should indicate to the nurse that the client has developed thrombus?

dull, aching calf pain

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPPA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

determine the location of the pain

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

"All recently used clothing, bedding, and towels must be washed in hot water."

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

"As a nurse, I am required by law to report suspected child abuse"

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Do you have difficulty staying awake when you are driving?

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

"The area surrounding the insertion site feels warm to the touch."

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

A nurse is assessing a client who reports numbness and pain his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?

Hold the wrist at a 90-degree flexion

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect?

Scaling and redness between the client's toes

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self- report of pain

Nurse is assessing a client who had left femoral angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer)

The left pedal pulse is the correct answer since the client had left-sided angiography.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location the nurse place her fingers?

The left second intercostal space

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Perform a neurovascular assessment

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (select all that apply).

Increased heart rate, increased blood pressure, increased respiratory

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema This is a sign of impaired circulation.

A nurse is completing a physical assessment who has early osteoarthritis. Which of the following manifestations should the nurse expect?

Pain worsens with activity

A nurse is speaking with the mother of a 6-year old child. Which of the following statements by the mother should concern the nurse?

"The teacher says my child has to squint to see the board"

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)

- Inspection - Auscultation - Superficial palpitation - Deep palpitation

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tablet(s)

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. which of the following notations should the nurse use to document the severity of the client's edema?

3+

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks

A nurse is admitting a client who has active tuberculosis to a room on a medical- surgical unit. Which of the following room assignments should the nurse make for the client?

A room w/ air exhaust directly to the outdoor environment

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

An increase in neutrophils & Localized edema

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A nurse is in a clinic interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment Assessment phases includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

At the end

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Auscultate for bruit Nurse should auscultate the AV graft site for the presence of a bruit or palpate the site for a thrill every 4 hr to assess for blood flow.

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Checkin capillary refill

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is caring for an adult who has atopic dermatitis. Which of the following findings should the nurse expect?

Chronic rash with thick skin

A nurse is assisting w/ the admission of a client to an inpatient unit. Which of the following sources of info. should the nurse rely on for accurate info about the client?

Client concerns Info the nurse obtains directly from the client is generally the most accurate and provides the best info. available. Client is the primary source of info

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 this client?

Conjunctivae

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (select all that apply)

Contractures of the extremities is correct, Crackles in the lungs, and pressure ulcers

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Dehydration

A nurse is assessing the reflexes of a client who has an un-repaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Dorsiflexion of the great toe

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (select all that apply.)

Dyspnea, Barrel chest, clubbing of the fingers

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?

Ecchymosis

A nurse is assessing an IV infusion site on an infants left hand. Which of the following findings should the nurse identify as an indication of an infiltration?

Edema

A nurse is having difficulty caring for a client due to variables affecting the communication. process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

Education, gender, and perception

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Evaluate chest expansion

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

Family history

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Fever

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum left-sided heart failure reduces cardiac output and raises pulmonary venous pressure.

A nurse is assessing a client who is African- American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice?

Hard palate According to EBP, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African- American

A nurse is assessing a client at a dermatology clinic. Which of the following findings places the client at risk for developing malignant melanoma?

History of chronic skin irritation

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

Hyperpigmentation Rationale: addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by wt. loss, muscle weakness, fatigue, low BP, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected find for this condition?

Hypoxemia

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic chook?

Increase in the heart rate from 88 to 110/min

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse info about the function of cranial nerve III?

Instruct the client to look up and down without moving his head

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in the client?

Kyphosis

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness would with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Laceration

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria Is a result of decreased blood flow to the kidneys

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (select all that apply.

Poor skin turgor, Hypotension, flat neck veins

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?

Prior to percussing the abdomen

The nurse is evaluating a client who had a cardiac catheterization w/ a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Radial pulse in the left arm

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

A nurse is assessing a client who is experiencing prostatic hypertrophy. which of the following findings associated with urinary retention should the nurse expect? (select all that apply).

Report of feeling pressure, tenderness over the symphysis pubis, distended bladder, voiding 30 mL frequently

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

Shivering

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Skin tenting present

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (select all that apply)

Slight pain at the insertion site, serous drainage on the dressing, minimal edema around the pin

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (select all that apply).

Sudden attacks of sleep & Hallucinations at the onset of sleep

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia

A nurse is caring for a client who has T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots", are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The third box from the top

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop An S3 represents ventricular gallop caused by a rush of blood into a ventricle that is stiff or dilated. This can be a finding of heart failure and hypertension

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (select all that apply).

Water heater temp 54.4 C & Throw rugs

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes

A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors?

When asking if the client took his medications this morning

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation?

clubbing of the fingers

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?

furrows in the tongue In older adults who are dehydrated the surface of the tongue will be dry with deep furrows

A nurse in ophthalmology clinic is interviewing a client who has referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report.

having a decreased ability to perceive colors