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Health Assessment Exam 2 ATI

Terms in this set (73)

A nurse is preparing to inspect a male client's abdomen. Which of the following should the nurse identify as an unexpected finding? Select all that apply.
-Everted umbilicus
-healed scars
-mole
-purple striae
-rash
-Everted umbilicus
-purple striae
-rash
A nurse is preparing to inspect a client's abdomen. Upon palpation, which of the following should the nurse report to the provider?
-Nontender
-Involuntary rigidity
-Relaxed muscles
-Adipose Tissue
Involuntary rigidity
A nurse is teaching a client about the purpose of probiotics and incorporating them in their diet. which of the following information should the nurse include?
Probiotics promote growth of good bacteria in the client's intestinal tract
A nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. which of the following information should the nurse include?
Fiber allows larger stool to soften and pass easier.
A nurse is providing teaching to a client about health promotion to prevent constipation. which of the following instructions should the nurse include?
Consume foods that are high in whole grains
A nurse is preparing to palpate a client's abdomen. which of the following findings should the nurse expect
-involuntary rigidity
-voluntary guarding
-boardlike
-nontender
nontender
A nurse is preparing to inspect a client's abdomen. which of the following variations should the nurse expect to find. Select all that apply
-silver striae
-rash
-taut skin
-healed scars
-mole
-Silver striae
-healed scars
-mole
A nurse is preparing to perform an assessment on a client's abdomen. which of the following pieces of equipment should the nurse use? Select all that apply.
-Stethoscope
-watch
-tape measure
-reflex hammer
-tuning fork
-stethoscope
-tape measure
-watch
A nurse is preparing to perform light palpation on a clients abdomen. In what order should the nurse perform?
-place client's arms at their side
-use the finger pads of one hand to palpate
-depress the client's abdomen using a dipping motion
-move fingers across the client's abdomen moving clockwise
-palpate painful areas
A nurse is preparing to auscultate the client's abdomen for the presence of bowel sounds. Which of the quadrants should the nurse listen to first.
Right Lower quadrant
A nurse is preparing to obtain information regarding a client's abdominal health history. which of the following questions should the nurse ask? Select all that apply.
-are you experiencing any abdominal pain
-do you take any medication
-have you noticed a change in your appetite
-when was your last bowel movement
-have you had any changes in your urinary output
-are you experiencing any abdominal pain
-do you take any medication
-have you noticed a change in your appetite
-when was your last bowel movement
A nurse is preparing to inspect the umbilicus of a client's abdomen. Which of the following findings should the nurse identify as an unexpected finding.
-swelling
-mole
-extraversion
-scar
Swelling
A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus?
Hyperactive bowel sounds
A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect?
-Dilated veins
-Stretch marks
-purple striae
-rash
Dilated veins
A nurse is providing teaching to a client about screening for colorectal cancer. Which of the following tests should the nurse include? Select all that apply.
-Fecal occult test
-Flex sigmoidoscopy
-Colonoscopy
-Barium enema with contrast
-Bronchoscopy
-Fecal occult
-flex sigmoidoscopy
-colonoscopy
-barium enema with contrast
A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds?
Bowel sounds heard after 2 minutes.
A nurse is performing range-of-motion exercises on a client's hips. The nurse is assessing which of the following motions by instructing the client to bend the knee and bring it toward the chest?
Flexion of the hip
A nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can?
Hyperextension
A nurse is assessing an older client while they walk. Which of the following findings should the nurse report to the provider?
The client walks with a shuffling gait
A nurse is assessing flexion of a client's elbow. The nurse should provide which of the following instructions to the client?
"Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders."
A nurse is preparing to perform palpation of a client's shoulder. In what order should the nurse perform the following steps?
-Face the client and palpate along the clavicle
-Face the client and palpate the acromioclavicular joint
-From the back, palpate the scapula
-From the back, palpate the greater tubercle of the humerus
A nurse is assessing the range of motions of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension.
Tilt the head back and look up at the ceiling.
A nurse is assessing a client's wrist and hands. Which of the following findings indicates the client might have arthritis. Select all that apply.
-Uneven skin tone
-Slight extension of the wrist
-Nodules on the joints
-A large mound below the thumb
-Fingers deviate toward the ulnar
-Nodules on the joints
-Fingers deviate toward the ulnar
A nurse is recommending sources of food with high calcium content to a client. Which of the following should the nurse recommend? Select all that apply.
-Milk
-Apples
-Mustard greens
-Corn
-Legumes
-Milk
-Mustard greens
-Legumes
A nurse is preparing palpation on a client's knees. In which order should the nurse perform the steps?
-Assist the client to a sitting position with the legs dangling at the edge of the examination table
-Palpate the quadriceps muscle above the knee
-Palpate the hollows on either side of the patella with the thumbs
-Follow the lower edge of the patella and locate the tibiofemoral joint
-Palpate the tibiofemoral joint where the femur and tibia meet
A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning from the nurse.
-"The bruise on my leg is from running into the base of a chair."
-"I'm sleeping better since I gave up caffeine in the afternoon."
-"For some reason I have been experiencing falls."
-"I no longer have back pain since I started walking 2 miles every day."
-"For some reason I have been experiencing falls."
A nurse is assessing the range of motion of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers?
-"Bend the thumb in toward the palm of the hand and then move it back out."
-"Make a fist and then straighten the fingers."
-"Spread the fingers apart and then move them back together."
-"Bend the thumb to touch the tip of each finger."
-"Spread the fingers apart and then move them back together."
A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take?
-Apply heat therapy after the first 24 hr following the injury.
-Place an ice pack directly on the injured area.
-Apply compression to the injured area of the extremity.
-Encourage the client to use the extremity as much as possible.
-Apply compression to the injured area of the extremity.
A nurse is providing teaching about adequate intake of Vit D to a client. Which of the following amounts should the nurse recommend?
800 IU Daily
A nurse is performing range-of-motion exercises on a client's feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet?
"Point your toes toward the floor."
"Turn the soles of your feet out, away from the body."
"Point your toes up toward your nose."
"Turn the bottoms of your feet in, toward the midline."
"Point your toes toward the floor."
The nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take.
-Perform the assessment from the toes to the head.
-Assess the extremities from distal to proximal.
-Perform passive range of motion before active range-of-motion movements.
-Inspect for symmetry on both sides of the body.
-Inspect for symmetry on both sides of the body.
A nurse is preparing a community program about injury prevention to a group of adults. Which of the following information should the nurse include. Select all that apply.
-Do not text and drive.
-Maintain spinal alignment when working at a desk.
-Remove loose rugs from the home.
-Use the back muscles when lifting objects.
-Wear a helmet when riding a bicycle.
-Do not text and drive.
-Maintain spinal alignment when working at a desk.
-Remove loose rugs from the home.
-Wear a helmet when riding a bicycle.
A nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider?
-C-7 is the most prominent vertebrae.
-Clicking is noted in the temporomandibular joint.
-The muscles of the neck are firm.
-There is locking of the jaw joint.
-There is locking of the jaw joint.
A nurse is assessing the spinal curvature of a client who has a diagnosis of kyphosis. What does that look like?
The nurse should recognize this image as kyphosis, an exaggerated posterior curvature of the thoracic spine. Kyphosis is associated with aging.
A nurse is providing teaching to a client who has osteoporosis about adequate intake of calcium. Which of the following intake amounts should the nurse recommend?
-500 to 1,000 mg daily
-1,000 to 1,200 mg daily
-1,500 to 2,000 mg daily
-2,000 to 2,200 mg daily
-1,000 to 1,200 mg daily
A nurse is caring for an older adult client who has an enlarged prostate and reports difficult voiding. Which of the following actions should the nurse take? Select all that apply.
-Perform a bladder scan within 60 min of the client voiding.
-Ensure that the client's intake is significantly greater than output.
-Inspect the client's suprapubic area for distention.
-Notify the provider if the bladder scan residual volume is greater than 100 mL.
-Ask the client if they are experiencing pain or a burning sensation when voiding.
-Inspect the client's suprapubic area for distention.
-Notify the provider if the bladder scan residual volume is greater than 100 mL.
-Ask the client if they are experiencing pain or a burning sensation when voiding.
A nurse is providing education to a male client about health promotion screenings. Which of the following information should the nurse include in the teaching?
-A digital rectal examination can detect enlargement of the prostate gland.
-The prostate-specific antigen (PSA) test evaluates semen for the presence of cancer cells.
-Testicular self-examination should be performed when the client is sitting in a cool environment.
-A client who has an average risk for colorectal cancer should have a colonoscopy every 2 years.
-A digital rectal examination can detect enlargement of the prostate gland.
A nurse is inspecting the genitalia of an older adult female client. For which of the following should the nurse notify the provider?
-Sparse pubic hair
-Atrophy of the mons pubis
-Dry vaginal membranes
-Labial ulceration
-Labial ulceration
A nurse is collecting a health history from a client. Which of the following statements requires further investigation?
-"I urinate a lot when I get up in the morning."
-"I have a bowel movement every morning after breakfast."
-"I have noticed that it burns when I urinate."
-"I empty my bladder several times a day."
-"I have noticed that it burns when I urinate."
A nurse is preparing to assist the provider with an assessment of a female client's genitourinary system. Which of the following actions should the nurse plan to take?
-Position the client supine with the head of the bed elevated.
-Avoid conversation while the provider is performing the assessment.
-Instruct the client to position their knees inward.
-Position the client's arms above their head.
-Position the client supine with the head of the bed elevated.
A nurse is conduction a health history interview with a client about their urinary system. The nurse should recognize that which of the following client reports could indicate the presence of declining kidney function? (select all that apply)
-Recent weight gain
-Hematuria
-Shortness of breath
-Swelling in the ankles
-Difficulty starting a urine stream
-Recent weight gain
-Shortness of breath
-Swelling in the ankles
A nurse is providing teaching about the prevention of sexually transmitted infections to a client who is sexually active and reports having multiple partners. Which of the following demonstrates an understanding of the teaching?
-"I should plan on getting tested each year for sexually transmitted infections."
-"Taking my birth control pills daily will prevent me from getting an infection."
-"Because I am at a low risk for HIV, I only need to get tested every other year."
-"Since I got the Hepatitis B vaccine, I am protected from sexually transmitted infections."
-"I should plan on getting tested each year for sexually transmitted infections."
A nurse is caring for a male client who reports the presence of yellow discharge from the meatus and burning with urination. Which of the following should the nurse suspect?
-Human papillomavirus (HPV)
-Urinary tract infection (UTI)
-Syphilis
-Gonorrhea
-Gonorrhea
A nurse is inspecting a client's rectal area and notes the presence of bulging red tissue that encompasses the entire anal opening. Which of the following should the nurse suspect?
-Rectal prolapse
A nurse is providing a bed bath for an older adult client who is immobile. Which of the following findings should the nurse report to the provider?
-A pendulous scrotal sac
-An inability to retract the foreskin
-Sparse pubic hair
-Left testicle is positioned lower than the right one
-An inability to retract the foreskin
A nurse is providing education to a female client who has expressed a desire to use a natural method on contraception. Which of the following methods should the nurse recommend? Select all that apply
-Condoms
-Withdrawal
-Fertility tracking with periodic abstinence
-Spermicidal sponge
-Tubal ligation
-Withdrawal
-Fertility tracking with periodic
The nurse is providing education to a young female client about the HPV vaccine. which of the following information should the nurse include in the teaching?
-The HPV vaccine is only recommended for female clients.
-An HPV infection can lead to the development of cancer.
-The HPV vaccine should be administered before age 18 to be effective.
-Immunization to prevent an HPV infection requires a single injection.
-An HPV infection can lead to the development of cancer.
A nurse is preparing to assess a client's genitalia. Which of the following actions should the nurse plan to take?
-Ensure the client has a full bladder.
-Use a firm, deliberate touch when palpating.
-Apply sterile gloves prior to touching the genitalia.
-Remove the drape from the lower half of the client's body.
-Use a firm, deliberate touch when palpating.
A nurse is preparing to assess a client for the presence of a hernia. Which of the following areas should the nurse plan to inspect? select all that apply
-Femoral area
-Inguinal area
-Rectal area
-Length of the shaft
-The circumference of the glans
-Femoral area
-Inguinal area
A nurse is inspecting the genitals of an adult male client. Which of the following should the nurse identify as expected findings. select all that apply
-Visible dorsal vein on the underside of the penile shaft
-Bilateral pea-sized (1 cm), soft testes
-Meatus located on the dorsal side of the glans
-Absence of pubic hair on the penile shaft
-Testes that are easily movable during palpation
-Visible dorsal vein on the underside of the penile shaft
-Absence of pubic hair on the penile shaft
-Testes that are easily movable during palpation
A nurse is preparing to assist with a prostate examination. Which of the following actions should the nurse plan to take?
-Supply sterile gloves for the provider.
-Provide the supplies for a specimen culture.
-Position the client standing, facing the examination table.
-Darken the lighting in the room.
-Position the client standing, facing the examination table.
A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform? 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 preparing to care for a group of clients in an acute car 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'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 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 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 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
A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?
-Inspect the pattern of hair distribution.
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 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 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 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
-Posture
-Nutritional status
-Hygiene
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 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 collection 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 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 auscultating breath sounds of a client and hears bronchial crackles. In which chest area is the nurse auscultating?
Trachea
A nurse is teaching a newly licensed nurse how to recognize pleural friction rub. Which of the following descriptions should the nurse use to describe pleural friction rub? (select all that apply)
-Coarse grating tone
-Intermittent popping or bubbling sound
-Heard of inspiration and expiration
-Snoring sound on expiration
-Pain with breathing
-Coarse grating tone
-Heard of inspiration and expiration
-Pain with breathing
A nurse is performing a head-to-toe assessment. Which of the following findings indicate the client might be experiencing respiratory difficulty? Select all that apply
-The client occasionally sighs.
-The client is sitting in a tripod position.
-The client's respiratory rate is 18/min.
-The client is using pursed lipped breathing.
-The client appears confused.
-The client is sitting in a tripod position.
-The client is using pursed lipped breathing.
-The client appears confused.
Which of the following manifestations should the nurse expect during hyperventilation?
-Numbness and tingling of extremities
-Decreased chest wall expansion
-Lightheadedness
-Periods of apnea
-Chest pain
-Numbness and tingling of extremities
-Lightheadedness
-Chest pain
A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?
Cheyne-Stokes breathing
A nurse is assessing a clients jugular veins and carotid arteries. The nurse should assist the client into what position?
Supine with the head of their bed at a 45 degree angle
A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider. Select all that apply
-Visible pulsations observed in the carotid area on both sides of the neck.
-Full, bounding pulse noted bilaterally in the carotid arteries upon palpation.
-Distention of the jugular vein on one side of the neck.
-Flattening of the jugular veins when the client sits upright.
-The left carotid artery pulse is weak.
-Full, bounding pulse noted bilaterally in the carotid arteries upon palpation.
-Distention of the jugular vein on one side of the neck.
-The left carotid artery pulse is weak.
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