ATI Health Assessment Exam 2

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss in left ear?

A. Air conduction is less than bone conduction in the left ear

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into? A. Trendelenburg B. Lying flat on back C. Tripod position D. Low Fowler's position

C. Tripod position

ER is assessing a client for closed pneumothorax and signifies bruising of the left chest following a motor- vehicle crash. The client reports sever left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?

A. Absence of breath sounds

In what order does blood flow through the heart valves?

1. Tricuspid valve 2. Pulmonic Valve 3. Mitral Valve 4. Aortic Valve

Which of the following instructions should you include while teaching a client about actions to promote the health of their head and neck? (select all that apply) A. "Use ear protection when attending a loud event" B. "Brush your teeth once a day" C. "Wear eye protection when cutting the grass" D. "Wear a bike helmet if you are going to participate in a bike race" E. "Limit music volume when using headphones"

A. "Use ear protection when attending a loud event" C. "Wear eye protection when cutting the grass" D. "Wear a bike helmet if you are going to participate in a bike race" E. "Limit music volume when using headphones

Which of the following statements should you include in teaching about health promotion screenings for adults? A. "You should have your vision checked every 2 years" B. "You only need your hearing checked if you think you have a problem" C. "You should have a dental exam every other year" D. "You can decrease the frequency of screening after the age of 60"

A. "You should have your vision checked every 2 years"

Which of the following ratings should you assign to abounding carotid pulse? A. + 4 B. +3 C. +2 D. +1

A. + 4

A nurse is assessing a clients Vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

B. Auscultation of the arteries for bruits with the bell of the stethoscope

When assessing the ear, which of the following is an emergency and requires immediately contacting the provider? A. Conductive hearing loss B. Bloody drainage from the ear following head trauma C. Edematous outer ear canal D. Yellow or green malodorous discharge

B. Bloody drainage from the ear following head trauma(The pressure of the type of drainage from the ear following head trauma could signify the presence of a fracture at the client's skull.)

Which of the following conditions is associated with jugular vein distention? A. Severe dehydration B. Heart failure C. Peripheral arterial disease D. Heart murmur

B. Heart failure

A nurse is caring for a client who is hyperventilating. The nurse should identify that which of the following circumstances can contribute to hyperventilation (Select all that applies). A. Nausea B. Pain C. Anxiety D. Fear

B. Pain C. Anxiety D. Fear

A nurse is assisting a client who is eating at mealtime. She starts choking, which should the nurse take first?

C. Determine whether the client is able to breathe

Which of the following pt reports indicates a medical emergency? A. "I have been wheezing when I am around flowers" B. "I forgot to take my water pill this morning" C. "I have a family history of heart disease" D. "I have a tight feeling in my chest"

D. "I have a tight feeling in my chest"

What is the scale rating for barely noticeable, mild pitting edema? A. + 4 B. +3 C. +2 D. +1

D. +1

A nurse is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which or the following complications?

D. Respiratory Obstruction

Expected Age related changes:

I should expect my heart rate to take longer to return to normal after exercise as I get older

The nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which should the nurse document?

Pericardial Friction Rub

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI?

Substernal Chest Pain

Which of the following are nursing interventions for chest pain? (select all that apply) A. Apply O2 B. Monitor vitals every 4 hours C. Encourage the client to ambulate D. Provide continuous ECG monitoring E. Obtain IV access

A. Apply O2 D. Provide continuous ECG monitoring E. Obtain IV access

Which of the following are the risk factors for heart disease? (select all that apply) A. BMI > 30 (obese) B. Smoking tobacco C. Aerobic exercise D. Hx of hypertension E. Type II diabetes

A. BMI > 30 (obese) B. Smoking tobacco D. Hx of hypertension E. Type II diabetes

For which of the following findings should you contact the provider? A. Clear one-sided nasal drainage in a client who fell down the stairs B. A clearly defined collection of blood in the sclera of a client who has been vomiting C. Dark yellow cerumen in the outer ear canal of a client who has been coughing D. Palpable lymph nodes in the neck of a client who has an upper respiratory infection

A. Clear one-sided nasal drainage in a client who fell down the stairs (clear or blood-tinged unilateral nasal drainage following head trauma might have a fracture at the base of their skull. Notify the provider of this finding)

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which cranial nerve are they testing?

A. Cranial Nerve XII

NNeurological assessment. By asking the client to stick out his tongue, which of the following cranial nerve testing?

A. Cranial Nerve XII (12)

Client has head injury with a possible skull fracture: The client might have a complication involving the 8th cranial nerve:

A. Dizziness and hearing loss

Assessing cranial nerve x: Which procedure to check?

A. Have the client open his mouth and say "Ahh"

Assessment of client's pupillary reaction to light order:

A. Have the client sit facing you at eye level B. Observe the pupils for size C. Darken the room D. Instruct the client to look at a distant object E. Move your penlight in from the side to shine on one pupil F. Observe the pupillary response in both eyes

A nurse is preparing education material for a client to maintain a healthy respiratory status. Which of the following information should the nurse include in the materials? (Select all that apply). A. Instruct and encourage the client to obtain the influenza vaccine B. Counsel the client about smoking cessation C. Educate the client that hand hygiene is the first line of defense to prevent illness. D. Inform the client that wearing a mask during the change of seasons prevents illnesses.

A. Instruct and encourage the client to obtain the influenza vaccine B. Counsel the client about smoking cessation C. Educate the client that hand hygiene is the first line of defense to prevent illness.

An older client who is having a stroke. After assessing the clients airway, breathing, and circulation, which of the following assessments is the nurse's priority?

A. Level of Consciousness: This poses more of a threat to client

A nurse is assessing a client and notes minimal air movement with the client's inspirations. Which of the following should the nurse recognize as a contributing factor? (Select all that apply). A. Pneumonia B. Chest Trauma C. Fever D. Prolonged bed rest

A. Pneumonia B. Chest Trauma D. Prolonged bed rest

The nurse is inspecting a client's anterior chest. Which of the following should the nurse inspect? A. Ribs sloping downward at an angle. B. Rales were noted along with the lower aspects of the lungs. C. Rib deformities felt at the thoracic level. D. The spine is without deformities.

A. Ribs sloping downward at an angle.

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which test?

A. Romberg

A nurse caring for a client immediately following exhibition. Which of the following manifestations indicates that the m=nurse should call the rapid response team?

A. Stridor

Which of the following are unexpected findings of the eyes? (Select all that apply.) A. Subconjunctival hemorrhage(a localized collection of blood on sclera caused by increase pressure in the eye from trauma.) B. Gingivitis C. Ptosis(drooping of the eyelid over the pupil and often result of edema or neurological disorder) D. Thrush E. Conjunctivitis(an inflammation of the eye that can be caused by viral or bacterial infections, allergies, or chemical irritation) E. Entropion(a condition in which the eyelids roll inward and can cause the lashes to touch and irritate the conjunctiva and cornea)

A. Subconjunctival hemorrhage (a localized collection of blood on sclera cause from increase pressure in the eye from trauma.) C. Ptosis (drooping of the eyelid over the pupil and often result of edema or neurological disorder) E. Conjunctivitis (an inflammation of the eye that can be caused by viral or bacterial infections, allergies, or chemical irritation) E. Entropion (a condition in which the eyelids roll inward and can cause the lashes to touch and irritate the conjunctiva and cornea)

Which of the following are signs of PAD? (select all that apply) A. Ulcers on the toes B. Leg pain that occurs with activity C. Decreased or absent pulses D. Warm skin temp: normal E. Bleeding ulcer on the leg: PVD

A. Ulcers on the toes B. Leg pain that occurs with activity C. Decreased or absent pulses

Which of the following should the nurse include when documenting objective findings? (select all that apply) A. Vital signs B. Inspection results C. Reason for pt encounter D. Plan of care E. Pt teaching

A. Vital signs B. Inspection results

Which of the following questions should you ask the client when assessing for an orientation deficit? (Select all that apply.) A. What is the date? B. What is your birthday? C. Do you know why you are here? D. Who is the president? E. What time is it? F. Where you from?

A. What's todays date? B. What is your birthday? C. Do you know why you are here? D. Who is the president? F. Where you from?

Which of the following tools are used in an assessment of the head and neck? (Select all that apply.) A. Tape measure B. Penlight C. Examination gloves D. Stethoscope E. Doppler F. Watch with second hand

B. Penlight(For the pupil response and visualization of the client's mouth and nares) C. Examination gloves(Inspecting the mouth and eyes and if there's any drainage from ears or nose.)

A nurse is inspecting a client and documents that the spine is straight and the movement upon inspiration is symmetrical. Which of the following describes the location that the nurse is documenting? A. The lateral Chest B. The posterior Chest(The posterior chest allows for inspection of both the spine and symmetry) C. The anterior Chest D. The abdomen

B. The posterior Chest (The posterior chest allows for inspection of both the spine and symmetry)

A nurse is completing a respiratory assessment of a client. Place the following steps in order when auscultating the posterior chest of the client. (In order)

C) 3 inches to the side of the spine at C7. A) 3 inches to the side of the spine at T4. D) Midaxillary line at T7. B) 3 inches to the side of the spine at the intercostal space of the 8th rib.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube.

C. Evaluate the client for stridor

A nurse is caring for a client who has difficulty breathing. The nurse should assist the client into which of the following positions?

C. Fowler's: Sitting upright promotes full expansion of lungs

A nurse is caring for a client who has an impairment of cranial nerve 2. which of the following actions should the nurse perform to promote client safety?

C. Provide an obstacle-free path for ambulation

Which of the following is an extra or unexpected heart sound?(Select all that apply) A. S1 B. S2 C. S3 D. S4 E. Murmur

C. S3 D. S4 E. Murmur

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse Identify as an indicator of impending respiratory failure?

C. Tachycardia: Sign of respiratory therapy

Which normal breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees? A. Tracheal(this is heard over the trachea and is high-pitched) B. Wheezing(this is an abnormal breath sound and whistle sound) C. Vesicular (This is normal breath sound that is heard over most of the lung fields with a soft sound like wind blowing through trees) D. Rales(this is an abnormal breath sound that is a cracking)

C. Vesicular (This is normal breath sound that is heard over most of the lung fields with a soft sound like wind blowing through trees)

Which of the following areas should the technique of palpation be used as part of the assessment: A. Eye structure B. Trachea C. Tongue D. Sinus cavities

D. Sinus cavities (Palpate the sinus area to assess for pain can indicate the presence of sinus infection)

ER Nurse and has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which action is priority for the nurse?

D. immobilize the clients cervical spine