ATI Introduction to Health Assessment Test
Assessment Explanation: The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing a client, and observing a client.
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?
Subjective Explanation: Subjective data includes feelings and concerns from the client's point of view. The reason why the client sought medical care is usually considered subjective data. This type of data, along with objective data, provides the nurse with information that will be reported to the provider.
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 data the nurse is collecting?
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 client's situation to understand the client's anxiety.焦虑
Palpate the tender areas of the abdomen last. Explanation: The client reported abdominal tenderness, so the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client.
A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?
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 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.
Penlight Tape measure Tongue depressor
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? (Select all that apply.) Penlight Tape measure Tongue depressor Needle and syringe Electrocardiogram (ECG) monitor
Skin temperature, moisture, and abnormalities Explanation: The nurse can make judgments about the findings of the skin, underlying tissue, muscle, and bones by palpating the skin for temperature, moisture, texture, and other abnormalities.纹理和其他异常
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?
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 the client using?
Autonomy
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 preparing to irrigate冲洗 a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply.) Goggles N95 mask Gown Gloves Surgical cap
Goggles The nurse should wear goggles or a face shield in case there is a threat of any bodily fluids splashing during wound care. Gown The nurse should don a gown to prevent their clothes from becoming soiled they were to come into contact with infected material, blood, or bodily fluids. Gloves The nurse should don gloves when providing hands-on care. The nurse should change gloves when either the task is completed or upon soilling.
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 performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates演示 the use of a nonverbal communication technique by the nurse?
Maintain a fair distance between self and client Explain: The nurse should maintain a personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.
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 auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment?
Stethoscope
