Ati nur 190/191 physical assessment final exam
Total Questions : 71
Showing 25 questions, Sign in for moreThe nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)
Explanation
A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.
B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.
C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.
D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.
E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.
A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.
A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?
Explanation
A. Generalized joint discomfort is not commonly associated with contact dermatitis; this condition typically affects the skin locally rather than causing systemic joint symptoms.
B. Systemic symptoms such as elevated temperature are generally not expected with contact dermatitis, as it is usually a localized skin reaction.
C. Pruritus (itching) is a common symptom of contact dermatitis, so denial of pruritus would not be expected.
D. Contact dermatitis often occurs due to exposure to a skin irritant, making a report of such exposure a typical finding in the assessment.
A nurse is assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.
A nurse has been assigned four patients, of which one of the patients has impaired immobility. Which complications should the nurse expect as a result of gout? (Select the four options that apply.)
Explanation
A. Erythema (redness) can occur at the site of a gout attack due to inflammation in the affected joint.
B. Hyperuricemia (elevated levels of uric acid in the blood) is a hallmark of gout, leading to the formation of urate crystals.
C. Pain is a prominent symptom of gout, particularly during an acute attack when joints become inflamed and tender.
D. Diarrhea is not a direct complication of gout; it is more associated with gastrointestinal issues or medications.
E. Edema (swelling) can occur in the affected joint due to inflammation associated with gout.
To determine the quality and intensity of a cardiac murmur, the nurse would take which action?
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.
A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?
Explanation
A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.
B. The radial pulse can be assessed bilaterally without risk.
C. The brachial pulse can also be assessed bilaterally without concern.
D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.
When a patient is unable to see objects at a distance, which term is used to document this finding?
Explanation
A. Presbyopia refers to age-related difficulty in seeing close objects due to loss of elasticity in the lens, not distance vision.
B. Astigmatism is a condition caused by an irregular curvature of the eye, leading to blurred vision at any distance.
C. Hyperopia (farsightedness) is the inability to see close objects clearly, not distant ones.
D. Myopia (nearsightedness) is the condition where a person cannot see objects at a distance clearly, making it the correct term for this finding.
A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which change is a manifestation of RA?
Explanation
A. Nodules, specifically rheumatoid nodules, can occur in RA, but they are not typically an early manifestation.
B. Fremitus is related to lung assessment and is not a manifestation of rheumatoid arthritis.
C. Tenderness in the soles of the feet is not a classic early manifestation of RA.
D. Joint swelling is one of the hallmark early signs of rheumatoid arthritis due to inflammation of the synovial membranes.
Which shape should the nurse expect a client's chest to be when assessing a client who has COPD?
Explanation
A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.
B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.
C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.
D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.
Which lung sounds are expected? (Select all that apply.)
Explanation
A. Bronchovesicular sounds are normal lung sounds that are typically heard over the mainstem bronchi and are expected during auscultation.
B. Bronchial sounds are also normal and are typically heard over the trachea; they are expected lung sounds.
C. Dullness is not a lung sound but rather a descriptor of percussion notes, typically indicating fluid or solid mass in the lungs.
D. Flatness is also not a normal lung sound but refers to a percussion note that can suggest the presence of fluid or a solid mass.
Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a group of lesions larger than 0.5 cm, with an elevated area of psoriasis. This is an example of a:
Explanation
A. A pustule is a small elevation of the skin that contains pus, typically smaller than 0.5 cm.
B. A macule is a flat, discolored area of skin that is less than 0.5 cm in diameter, so it does not fit the description of elevated lesions larger than 0.5 cm.
C. A papule is an elevated, solid lesion that is less than 0.5 cm in diameter; lesions larger than this would not be classified as papules.
D. A patch is defined as a flat, non-palpable lesion larger than 0.5 cm, and psoriasis can present as patches. Thus, the lesions described fit this classification.
A nurse is caring for a client and observes that the client's urine is cloudy, has an unpleasant odor, and contains hematuria. The nurse should recognize that these findings are associated with which urinary problem?
Explanation
A. Urinary frequency is characterized by the need to urinate more often but does not necessarily cause cloudy urine, odor, or hematuria.
B. Urinary retention involves the inability to empty the bladder fully but does not specifically present with cloudy urine, odor, or blood.
C. Urinary incontinence refers to the involuntary loss of urine and does not directly correlate with the urine's appearance or presence of blood.
D. A urinary tract infection (UTI) commonly causes cloudy urine, foul odor, and hematuria due to inflammation and infection in the urinary tract.
A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?
Explanation
A. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.
B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.
C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.
D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.
The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Explanation
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
A nurse is caring for a client who has a body mass index (BMI) of 26. The nurse should place the client in which BMI category?
Explanation
A. A BMI of 26 is not classified as obese; obesity typically starts at a BMI of 30.
B. Underweight is defined as a BMI less than 18.5, which does not apply to this client.
C. A BMI of 26 falls within the overweight category, which is defined as a BMI between 25 and 29.9.
D. A healthy weight is classified as a BMI between 18.5 and 24.9, which does not include a BMI of 26.
To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?
Explanation
A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.
B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.
C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.
D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.
Which finding should the nurse expect when assessing a client who is cyanotic?
Explanation
A. Bradypnea (slow breathing) may occur in various conditions but is not a defining characteristic of cyanosis.
B. A pale reddish color in the skin is not consistent with cyanosis, which indicates a lack of oxygen in the blood.
C. Somnolence (drowsiness) may be present in some patients, but it is not a specific finding related to cyanosis.
D. Mottled blue color in the skin is a classic sign of cyanosis, indicating inadequate oxygenation of the blood, especially in the extremities or areas with poor circulation.
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
Explanation
A. Auscultating the area may not provide information about the dorsalis pedis pulse, which is a palpated pulse.
B. Using Doppler ultrasonography is the most appropriate next step to locate the dorsalis pedis pulse if it cannot be palpated, as it provides a non-invasive way to detect blood flow.
C. While documenting the absence of the pulse is necessary, it should be done after attempts to locate the pulse have been made.
D. It is not immediately necessary to ask a provider to assess the pulse; the nurse can use Doppler ultrasonography first to gather more information.
A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)
Explanation
A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.
B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.
C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.
D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.
E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?
Explanation
A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.
B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.
C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.
D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.
A nurse is teaching about the risk factors of developing a stroke with a group of older adult clients. Which nonmodifiable risk factors should the nurse include in the teaching?
Explanation
A. Obesity is a modifiable risk factor, as it can be addressed through lifestyle changes such as diet and exercise.
B. Race is a nonmodifiable risk factor; certain races may have a higher risk of stroke due to genetic and environmental factors.
C. History of smoking is a modifiable risk factor because individuals can choose to quit smoking to reduce their risk of stroke.
D. History of hypertension is also a modifiable risk factor; while having high blood pressure increases the risk of stroke, it can be managed with lifestyle changes and medications.
A nurse in a clinic is 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?
Explanation
A. The planning phase involves setting goals and determining interventions based on the assessment data.
B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.
C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.
D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.
Which technique would the nurse use to perform scoliosis screening in a school-age child?
Explanation
A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.
B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.
C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.
D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.
A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?
Explanation
A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.
B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.
C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.
D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.
Sign Up or Login to view all the 71 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
