ATI health assessment exam 1, 2 and
final
1. A nurse is introducing herself to a client as the first step of a
comprehensive physical examination. Which of the following
strategies should the nurse use with this client? (select all that
apply)
A. Address the client with the appropriate title and her last
name. B. Use a mix of open- and close-ended questions. C. Reduce environmental noise. D. Have the client complete a health history form. E. Perform the general survey before the examination. B, C, E
Rationale:
B. Open- ended questions help the client tell her story in her
own way. Closed- ended questions are useful for clarifying and
verifying information the nurse gathers from the client's story
C. quiet, comfortable environment eliminates distractions and
helps the client focus on the important aspects of the interview. E. The general survey is noninvasive and, along with the health
history and vital sign measurement, can help put the client at
ease before the more sensitive parts of the process, such as the
examination
A nurse in a provider's office is documenting his findings
following an examination he performed for a client new to the
practice. Which of the following parameters should he include
as part of the general survey? (Select all that apply.)
A. Posture
B. Skin lesions
C. Speech
D. Allergies. E. immunization status
A, B, C
Rationale:
A. Posture is part of the body structure or general appearance
portion of the general survey. B. Skin lesions are part of the body structure or general
appearance portion of the general survey. C. Speech is part of the behavior portion of the general survey
A nurse is collecting data for a client's comprehensive physical
examination. after the nurse inspects the client's abdomen,
which of the following skills of the physical examination process
should she perform next?
A.olfaction
B.auscultation
C.Palpation
D.Percussion
B
Rationale:
B. Because palpation and percussion can alter the frequency
and intensity of bowel sounds, the nurse should auscultate the
abdomen next and before using those two techniques
A nurse is performing a comprehensive physical examination of
an older adult client. Which of the following interventions
should the nurse use in consideration of the client's age?
(Select all that apply.)
a.Collect the data in one continuous session. B.Plan to allow plenty of time for position changes. C.Make sure the client has any essential sensory aids in place. D. tell the client to take her time answering questions. E. invite the client to use the bathroom before beginning the
examination
B, C, D, E
Rationale:
B. Because many older adults have mobility challenges, the
nurse should plan to allow extra time for position changes. C. the nurse should make sure clients who use sensory aids
have them available for use. the client has to be able to hear
the nurse and see well enough to avoid injury. D. Some older clients need more time to collect their thoughts
and answer questions, but most are reliable historians. Feeling
rushed can hinder communication. E. This is a courtesy for all clients, to avoid discomfort during
palpation of the lower abdomen for example, but this is
especially important for older clients who have a smaller
bladder capacity. A nurse in a family practice clinic is performing a physical
examination of an adult client. Which part of her hands should
she use during palpation for optimal assessment of skin
temperature?
A.Palmar surface
B.Fingertips
C.Dorsal surface
D.Base of the fingers
C
Rationale:
C. The dorsal surface of the hand is the most sensitive to
temperature. A nurse is caring for an 82- year- old client in the emergency
department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is
restless and his skin is warm. Which of the following
interventions should the nurse take? (Select all that apply.)
A.Obtain culture specimens before initiating antimicrobials. B.Restrict the client's oral fluid intake. C.Encourage the client to rest and limit activity. D. allow the client to shiver to dispel excess heat. E. assist the client with oral hygiene frequently
A, C, E
Rationale:
A. he provider can prescribe cultures to identify any infectious
organisms causing the fever. the nurse should obtain culture
specimens before antimicrobial therapy to prevent interference
with the detection of the infection. C.Rest helps conserve energy and decreases metabolic rate. activity can increase heat production
E. Oral hygiene helps prevent cracking of dry mucous
membranes of the mouth and lips
A nurse is instructing an assistive personnel (aP) about caring
for a client who has a low platelet count as a result of
chemotherapy. Which of the following instructions is the
priority for measuring vital signs for this client?
A."Do not measure the client's temperature rectally."
B."Count the client's radial pulse for 30 seconds and multiply it
by 2."
C."Do not let the client know you are counting her
respirations."
D."let the client rest for 5 minutes before you measure her
blood pressure."
Category | ATI |
Pages | 24 |
Language | English |
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