ATI HealthAssess 2.0 Head to toe assessment Learning Module Test

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. Begin auscultation in the left upper quadrant. Auscultate bowel sounds prior to palpating. Count the number of bowel sounds auscultated over 1 min.

Auscultate bowel sounds prior to palpating.

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. Observe the client's gait as they walk across a room. Use a sharp pin to assess for sensation on the sole of the client's foot. Inspect the pattern of hair distribution.

Inspect the pattern of hair distribution.

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? (Select all that apply.) Lung sounds Bowel sounds Measurement of abdominal girth Pedal pulses Mental status

Lung sounds Bowel sounds Pedal pulses Mental status

A nurse is performing an assessment on a client who reports ear pain. Which of the following actions should the nurse take? Palpate the temporomandibular joint for pain. Palpate the mastoid area for pain. Inspect the nasal mucosa for redness. Inspect the conjunctival sac for redness.

Palpate the mastoid area for pain.

A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider? Distended veins in one breast Costal margin of 85° PMI located to the left of the midclavicular line at the 4th intercostal space Symmetrical chest expansion during the inspiratory phase

Distended veins in one breast

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? (Select all that apply.) Instruct the client to swallow. Apply downward pressure and ask the client to shrug their shoulders. Tell the client to open their mouth and say "ahhh." Test the client's ability to protrude their tongue. Request the client move their head forward and backward and then side to side.

Instruct the client to swallow. Apply downward pressure and ask the client to shrug their shoulders. Request the client move their head forward and backward and then side to side.

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. Observe for the use of accessory muscles during inspiration. Begin auscultating at the level of C4. Reposition the stethoscope downward at 4 inch (10 cm) intervals.

Observe for the use of accessory muscles during inspiration.

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? (Select all that apply.) Blood glucose meter Penlight Stethoscope Sphygmomanometer Sterile gloves

Penlight Stethoscope Sphygmomanometer

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. Include the nurse's interpretation when recording objective information. Perform the assessment in the same order. Use quotation marks when documenting client statements.

Use quotation marks when documenting client statements.

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? (Select all that apply.) During an interview about the client's health history When introducing themselves to the client Once the focused assessments have been completed While collecting the client's vital signs During the discussion of planning for follow-up care

During an interview about the client's health history When introducing themselves to the client While collecting the client's vital signs

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take? (Select all that apply.) Inspect the condition of each fingernail. Apply a pulse oximeter to a finger. Compare the amplitude of the radial pulses bilaterally. Evaluate blood pressure in an upper extremity. Palpate the shoulder, elbow, wrist, and finger joints.

Inspect the condition of each fingernail. Compare the amplitude of the radial pulses bilaterally. Palpate the shoulder, elbow, wrist, and finger joints.

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should be nurse inspect when performing a general survey of the client? (Select all that apply.) Nutritional status Hygiene Lung expansion Posture Range-of-motion

Nutritional status Hygiene Posture

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action? (Select all that apply.) Depth of pedal pitting edema Regularity of the pulse Presence of a murmur Presence of a bruit Strength of the pulse

Regularity of the pulse Strength of the pulse

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?" "Can you tell me what month it is?" "Can you tell me what you had for lunch yesterday?" "Can you repeat the four words that I asked you to remember?"

"Can you tell me what month it is?"

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 Symmetric expansion of the chest walls Shape and alignment of the rib cage Intensity of tactile fremitus

Characteristics of the respirations