Unit XVIII - Health Assessment

Question 1

ATI - Health Assessment (Adult) Module

When using and maintaining your stethoscope, it is important to

A. insert the earpieces at an angle toward your nose.
B. use the diaphragm for listening to low-pitched sounds.
C. drape the stethoscope over your neck when not in use.
D. clean your stethoscope by immersing it in soapy water.

Answer 1

A. insert the earpieces at an angle toward your nose.

Rationale:
Angling the earpieces toward your nose helps ensure that sounds are effectively transmitted to your eardrums.

Question 2

ATI - Health Assessment (Adult) Module

When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient’s foot between the extensor tendons of the great toe and those of the toe next to it. Which pulse are you palpating?

A. Posterior tibial
B. Popliteal
C. Dorsalis pedis
D.Femoral

Answer 2

C. Dorsalis pedis

Rationale:
In the lower extremities, the most common pulse tested is the dorsalis pedis pulse, found on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.

Question 3

ATI - Health Assessment (Adult) Module

While performing an abdominal assessment, you place your fingertips over the patient’s painful area and gradually increase pressure, then quickly release it. The patient reports increased pain on release of the pressure, so you document that your patient has positive

A. borborygmi.
B. rebound tenderness.
C. tympany.
D. abdominal guarding

Answer 3

B. rebound tenderness.

Rationale:
This procedure elicits rebound tenderness - an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney’s point (one third distance from the anterior iliac crest to the umbilicus) is a sign of acute appendicitis.

Question 4

ATI - Health Assessment (Adult) Module

As part of your general patient survey, you find that your patient has a body mass index (BMI) of 23. From this finding, you can conclude that your patient

A. has no nutritional problems or deficits.
B. is at high risk for obesity-related health problems.
C. needs a referral to a nutritional counselor.
D. has a body mass index within normal limits.

Answer 4

D. has a body mass index within normal limits.

Rationale:
BMI is a measurement of an adult’s body fat based on height and weight. Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a normal amount of body fat. A patient with a BMI below 18.5 is considered underweight; a patient with a BMI of 25 or above is considered overweight; and one with a BMI of 30 or above is considered obese.

Question 5

ATI - Health Assessment (Adult) Module

When performing a complete, head-to-toe physical examination, which physical assessment technique should you perform first?

A. Auscultation
B. Inspection
C. Percussion
D. Palpation

Answer 5

B. Inspection

Rationale:
Inspection is the process of observation. You will first inspect the body systematically, observing for normal as well as abnormal physical signs. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation. Abdominal assessment is an exception, since any manipulation of or pressure on the abdomen may stimulate peristalsis, the waves of contraction that propel contents through the GI tract, and thus alter the patient’s bowel sounds. So, when assessing the abdomen, inspection is still first, but auscultation comes before percussion and palpation.

Question 6

ATI - Health Assessment (Adult) Module

What is your primary goal in performing a comprehensive physical assessment?

A. To document accurate data
B. To develop a plan of care
C. To validate previous data
D. To evaluate outcomes of care

Answer 6

B. To develop a plan of care

Rationale:
Remember the nursing process: assessment, diagnosis, planning, implementation, evaluation. Assessment is the first part of the process. It generates the database from which you will make nursing decisions. Your objective in interacting with patients to identify their needs and concerns and help find solutions. That is the nursing process in action - and your map is the nursing care plan you establish for each patient. Analyzing and synthesizing data will provide the basis for each nursing diagnosis and for the selection of nursing interventions to manage actual or potential health problems.

Question 7

ATI - Health Assessment (Adult) Module

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

A. Right upper quadrant
B. Left upper quadrant
C. Right lower quadrant
D. Left lower quadrant

Answer 7

C. Right lower quadrant

Rationale:
To the right of the umbilicus is the right lower quadrant is the ileocecal valve. This is where the small intestine connects to the large intestine, and is normally very active with bowel sounds. Many nurses begin listening here for that reason. For the average adult, you’ll hear five to 30 bowel sounds/minute.

Question 8

ATI - Health Assessment (Adult) Module

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following findings is considered normal?

A. A continuous sensation of vibration felt over the second and third left intercostal spaces
B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum
C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line
D. A whooshing or swishing sound over the second intercostal space along thee left sternal border

Answer 8

C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

Rationale:
This is where you would inspect and palpate for the PMI. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is a normal and expected finding when you are preparing to auscultate an apical pulse.

Question 9

ATI - Health Assessment (Adult) Module

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as

A. crackles.
B. stridor.
C. wheezes.
D. friction rub.

Answer 9

A. crackles.

Rationale:
Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration.

Question 10

ATI - Health Assessment (Adult) Module

While examining your patient’s head and face, you determine that cranial nerve I is intact when the patient follows your instructions and successfully

A. sticks his tongue out.
B. smiles symmetrically.
C. hears whispered words.
D. identifies a minty scent.

Answer 10

D. identifies a minty scent.

Rationale:
Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve’s function, ask the patient to identify a nonirritating aroma, such as mint or coffee.

Question 11

ATI - Health Assessment (Adult) Module

While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient’s

A. gait.
B. hearing.
C. vision.
D. balance.

Answer 11

D. balance.

Rationale:
The most common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of you, with his/her feet together, toes pointed forward, and her hands at her sides. While you extend your hands so that one is on either side of the patient, ask the patient to close his eyes. Watch to see how well he can maintain balance in that position. A minimum of swaying is normal, but if the patient sways more than a couple of inches, stop the test and document that the patient demonstrated difficulty maintaining balance on Romberg testing.

Question 12

ATI - Health Assessment (Adult) Module

You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging?

A. Lordosis
B. Kyphosis
C. Anklosis
D. Scoliosis

Answer 12

B. Kyphosis

Rationale:
Kyphosis is the curvature of the spine and is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older patients who have had vertebral fractures.

Question 13

ATI - Health Assessment (Child) Module

Which of the following techniques is appropriate when obtaining a blood pressure on a child?

A. Position the arm below the level of the heart while the child is sitting in a chair.
B. Release the cuff pressure at a rate of 4 to 5 mm Hg.
C. Inflate the blood pressure cuff slowly.
D. Use a cuff with a bladder covering 80 to 100% of the arm circumference.

Answer 13

D. Use a cuff with a bladder covering 80 to 100% of the arm circumference.

Rationale:
The bladder should cover 80 to 100% of the arm circumference to obtain an accurate reading.

Question 14

ATI - Health Assessment (Child) Module

Which of the following communication techniques is most appropriate for a nurse to employ during the physical examination of a 10 year old?

A. Allow the child to play with the equipment.
B. Encourage expression of thought through puppets.
C. Use books and other visual aids to advance the interview.
D. Use abstract questions to allow the child more freedom in response.

Answer 14

C. Use books and other visual aids to advance the interview.

Rationale:
This technique is very useful for working with school-age children.

Question 15

ATI - Health Assessment (Child) Module

A nurse is testing a child for strabismus. Which of the following is the correct technique for performing this examination?

A. Check for presence of the red reflex.
B. Check for visual acuity.
C. Perform the cover-uncover test.
D. Test for pupillary reaction to light.

Answer 15

C. Perform the cover-uncover test.

Rationale:
This test identifies whether a child has strabismus, or nonbinocular vision.

Question 16

ATI - Health Assessment (Child) Module

When performing an otoscopy examination on a 2-year-old child, the nurse should pull the pinna

A. down and back.
B. down and forward.
C. up and back.
D. up and forward.

Answer 16

A. down and back.

Rationale:
This is the correct technique for straightening the ear canal because the ear canal of a 2 year old curves upward.

Question 17

ATI - Health Assessment (Child) Module

A nurse is performing an abdominal examination on a preschooler. Which of the following instructions should the nurse give to the child when performing abdominal palpation?

A. Hold your breath.
B. Place your hand under mine.
C. Turn on your right side.
D. Raise your arms over your head.

Answer 17

B. Place your hand under mine.

Rationale:
Allowing the child to touch her abdomen during the examination will promote relaxation.

Question 18

ATI - Health Assessment (Child) Module

A nurse is performing an annual physical examination on an adolescent. Which of the following should be included in the general survey?

A. The patient’s deep tendon reflexes are 2+ bilaterally.
B. The patient is able to read small print at 14 inches.
C. The patient demonstrates short-term recall.
D. The patient makes good eye contact.

Answer 18

D. The patient makes good eye contact.

Rationale:
This information is included in the general survey. The general survey includes identifying the patient’s demeanor, mood, and interactions with others.

Question 19

ATI - Health Assessment (Child) Module

When assessing a school-age child and adolescent for scoliosis,it is important to have the child

A. bend the knees and touch the toes.
B. stand up straight with the arms at the side.
C. bend forward with the knees straight and the arms dangling.
D. lie prone with the arms extended.

Answer 19

C. bend forward with the knees straight and the arms dangling.

Rationale:
This position allows for adequate visualization of any asymmetry.

Question 20

ATI - Health Assessment (Child) Module

A nurse is examining an 18-month old child’s ears during a well-child visit. Which of the following techniques should the nurse use?

A. Position the child on his side and have the parents hold the arms and head down.
B. Have the parent hold the child securely in her lap.
C. Ask another nurse to come into the room and hold the child.
D. Restrain the child using a blanket to secure his arms at this sides.

Answer 20

B. Have the parent hold the child securely in her lap.

Rationale:
A parent’s lap is the most comfortable and secure position for the child.

Question 21

ATI - Health Assessment (Child) Module

A nurse is documenting findings from a physical examination. Which of the following statements indicates correct charting?

A. “Bowel gurgling at 24 per minute, hear in left upper quadrant, right upper quadrant, left lower quadrant, and right lower quadrant.”
B. “No problems breathing. Lungs clear.”
C. “Liver palpation is normal.”
D. “Regular heart rate and rhythm: S1, S2 heard.”

Answer 21

D. “Regular heart rate and rhythm: S1, S2 heard.”

Rationale:
This clear, concise charting for normal heart sounds.

Question 22

ATI - Health Assessment (Child) Module

A nurse is obtaining a problem-oriented history from a preschooled-aged child. The nurse should consider that children from this age group typically can

A. describe the symptoms.
B. identify when the problem started.
C. specify the cause of the problem.
D. answer questions related to previous health problems.

Answer 22

A. describe the symptoms.

Rationale:
Preschoolers are usually able to describe symptoms of their problem.

Question 23

Berman Textbook - Chapter 17

Which of the following indicates a normal nursing assessment finding on auscultation of the lungs?

A. Tympany over the right upper lobe
B. Resonance over the left upper lobe
C. Hyperresonance over the left lower lobe
D. Dullness above the left 10th intercostal space

Answer 23

B. Resonance over the left upper lobe

Rationale:
Resonance is a normal sound over the lung. Tympany (Option A) would be heard over the stomach (air filled), hyperresonnance (Option C) is never a normal finding, and dullness (Option D) would be heard below (not above ) the 10th intercostal space.

Question 24

Berman Textbook - Chapter 17

The nurse positions the client sitting upright during palpation of which of the following areas?

A. Abdomen
B. Genitals
C. Breast
D. Head and Neck

Answer 24

D. Head and Neck

Rationale:
The client would sit for examination of the head and neck. For palpation of the abdomen, genitals, and breast, the client should be supine (Option A, B, and C)

Question 25

Berman Textbook - Chapter 17

After auscultating the abdomen, the nurse should report which of the following to the primary care provider?

A. Bruit over the aorta
B. Absence of bowel sounds for 60 seconds
C. Continuous bowel sounds over the ileocecal valve after a meal
D. A completely irregular pattern of bowel sounds

Answer 25

A. Bruit over the aorta

Rationale:
A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. In order for absence of bowel sounds to be completed abnormal, they must be silent for 3 to 5 minutes (Option B). Continuous bowel sounds are normal heard over the ileocecal valve following meals (Option C). Bowel sounds are more commonly irregular than they are regular (Option D).

Question 26

Berman Textbook - Chapter 17

If unable to locate the client’s popliteal pulse during a routine examination, the nurse should perform which of the following next?

A. Check for a pedal pulse.
B. Check for a femoral pulse.
C. Take the client’s blood pressure on that thigh.
D. Ask another nurse to try to locate the pulse.

Answer 26

A. Check for a pedal pulse.

Rationale:
If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial than the arterial circulation to the leg is present even though the popliteal artery has not been located. Another option, not provided in the question, would be to perform Doppler ultrasound to see if popliteal pulses could be heard. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (Option B). Taking a thigh BP requires locating the popliteal pulse (Option C). Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (Option D).

Question 27

Berman Textbook - Chapter 17

Which of the following is an expected finding during the nurse’s assessment of the older adult?

A. Facial hair becomes finer and softer.
B. Decreased peripheral, color, and night vision.
C. Increased sensitivity to odors.
D. Respiratory rate and rhythm are irregular at rest.

Answer 27

B. Decreased peripheral, color, and night vision.

Question 28

Berman Textbook - Chapter 17

List five aspects of the skin that the nurse assesses during a routine examination.

Answer 28

1. Color
2. Temperature
3. Turgor
4. Odor
5. Lesions

Rationale:

Question 29

Berman Textbook - Chapter 17

If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

A. Have the client repeat a series of three numbers, increasing to eight if possible.
B. Have the client describe his or her childhood illness
C. Ask the client to describe how he or she arrived at this location
D. Ask the client to count backward from 100 subtracting seven each time.

Answer 29

C. Ask the client to describe how he or she arrived at this location

Rationale:
Recent memory includes events of the current day. Recalling a series of numbers test immediate recall (Option A). Recalling childhood events tests remote (long-term) memory (Option B) and subtracting backwards from 100 tests attention span and calculation skills (Option D)

Question 30

Berman Textbook - Chapter 17

In order to palpate lymph nodes, the nurse uses which of the following techniques?

A. Use the flat or all four fingers in a vertical and then side-to-side motion.
B. Use the back of the hand and feel for temperature variation between the right and left sides.
C. Use the pads of two fingers a circular motion.
D. Compress the nodes between the index fingers of both hands.

Answer 30

C. Use the pads of two fingers a circular motion.

Question 31

Berman Textbook - Chapter 17

For a client whose assessment of the musculoskeletal system is normal, the nurse checks which of the following on the medical record? Select all that apply.

A. Atrophied
B. Contractured
C. Crepitation
D. Equal
E.Firm

Answer 31

D. Equal

E.Firm

Question 32

Berman Textbook - Chapter 17

What is resonance?

Answer 32

It is the hollow sound such as that is produced by the lungs filled with air.

Question 33

Berman Textbook - Chapter 17

What is Hyperresonance?

Answer 33

It is not an anticipated finding. It is described as booming and can be heard over emphysematous lung.

Question 34

Berman Textbook - Chapter 17

What is Tympany?

Answer 34

It is a musical or drumlike sound produced from an air-filled stomach.

Question 35

Physical Assessment Powerpoint

What are the 5 Ps when assessing someone after surgery or a diagnostic test?

Answer 35

Pain
Pallor
Paralysis
Parasthesia
Pulse

Question 36

Berman Textbook - Chapter 17

Which of the following indicates a normal nursing assessment finding on auscultation of the lungs?

A. Tympany over the right upper lobe
B. Resonance over the left upper lobe
C. Hyperresonance over the left lower lobe
D. Dullness above the left 10th intercostal space

Answer 36

B. Resonance over the left upper lobe

Rationale:
Resonance is a normal sound over the lung. Tympany (Option A) would be heard over the stomach (air filled), hyperresonnance (Option C) is never a normal finding, and dullness (Option D) would be heard below (not above ) the 10th intercostal space.

Question 37

Berman Textbook - Chapter 17

The nurse positions the client sitting upright during palpation of which of the following areas?

A. Abdomen
B. Genitals
C. Breast
D. Head and Neck

Answer 37

D. Head and Neck

Rationale:
The client would sit for examination of the head and neck. For palpation of the abdomen, genitals, and breast, the client should be supine (Option A, B, and C)

Question 38

Berman Textbook - Chapter 17

After auscultating the abdomen, the nurse should report which of the following to the primary care provider?

A. Bruit over the aorta
B. Absence of bowel sounds for 60 seconds
C. Continuous bowel sounds over the ileocecal valve after a meal
D. A completely irregular pattern of bowel sounds

Answer 38

A. Bruit over the aorta

Rationale:
A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. In order for absence of bowel sounds to be completed abnormal, they must be silent for 3 to 5 minutes (Option B). Continuous bowel sounds are normal heard over the ileocecal valve following meals (Option C). Bowel sounds are more commonly irregular than they are regular (Option D).

Question 39

Berman Textbook - Chapter 17

If unable to locate the client’s popliteal pulse during a routine examination, the nurse should perform which of the following next?

A. Check for a pedal pulse.
B. Check for a femoral pulse.
C. Take the client’s blood pressure on that thigh.
D. Ask another nurse to try to locate the pulse.

Answer 39

A. Check for a pedal pulse.

Rationale:
If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial than the arterial circulation to the leg is present even though the popliteal artery has not been located. Another option, not provided in the question, would be to perform Doppler ultrasound to see if popliteal pulses could be heard. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (Option B). Taking a thigh BP requires locating the popliteal pulse (Option C). Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (Option D).

Question 40

Berman Textbook - Chapter 17

Which of the following is an expected finding during the nurse’s assessment of the older adult?

A. Facial hair becomes finer and softer.
B. Decreased peripheral, color, and night vision.
C. Increased sensitivity to odors.
D. Respiratory rate and rhythm are irregular at rest.

Answer 40

B. Decreased peripheral, color, and night vision.

Question 41

Berman Textbook - Chapter 17

List five aspects of the skin that the nurse assesses during a routine examination.

Answer 41

1. Color
2. Temperature
3. Turgor
4. Odor
5. Lesions

Rationale:

Question 42

Berman Textbook - Chapter 17

If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

A. Have the client repeat a series of three numbers, increasing to eight if possible.
B. Have the client describe his or her childhood illness
C. Ask the client to describe how he or she arrived at this location
D. Ask the client to count backward from 100 subtracting seven each time.

Answer 42

C. Ask the client to describe how he or she arrived at this location

Rationale:
Recent memory includes events of the current day. Recalling a series of numbers test immediate recall (Option A). Recalling childhood events tests remote (long-term) memory (Option B) and subtracting backwards from 100 tests attention span and calculation skills (Option D)

Question 43

Berman Textbook - Chapter 17

In order to palpate lymph nodes, the nurse uses which of the following techniques?

A. Use the flat or all four fingers in a vertical and then side-to-side motion.
B. Use the back of the hand and feel for temperature variation between the right and left sides.
C. Use the pads of two fingers a circular motion.
D. Compress the nodes between the index fingers of both hands.

Answer 43

C. Use the pads of two fingers a circular motion.

Question 44

Berman Textbook - Chapter 17

For a client whose assessment of the musculoskeletal system is normal, the nurse checks which of the following on the medical record? Select all that apply.

A. Atrophied
B. Contractured
C. Crepitation
D. Equal
E.Firm

Answer 44

D. Equal

E.Firm

Question 45

Berman Textbook - Chapter 17

What is resonance?

Answer 45

It is the hollow sound such as that is produced by the lungs filled with air.

Question 46

Berman Textbook - Chapter 17

What is Hyperresonance?

Answer 46

It is not an anticipated finding. It is described as booming and can be heard over emphysematous lung.

Question 47

Berman Textbook - Chapter 17

What is Tympany?

Answer 47

It is a musical or drumlike sound produced from an air-filled stomach.

Question 48

Physical Assessment Powerpoint

What are the 5 Ps when assessing someone after surgery or a diagnostic test?

Answer 48

Pain
Pallor
Paralysis
Parasthesia
Pulse

Question 49

ATI Textbook - Chapter 27

An 82-year-old man arrives at the emergency department with an oral body temperature of 101ºF, a pulse rate of 114/min, and respiratory rate of 22/min. He is restless and his skin is warm to the touch. Which of the following are appropriate nursing interventions for this client? (Select all that apply)

A. Obtain culture specimens before initiating prescribed antimicrobials.
B. Restrict fluids.
C. Allow for adequate rest.
D. Provide oral care.
E. Only change bed linens when the client requests it.
F. Apply an additional blanket if the client feels chilled.

Answer 49

A. Obtain culture specimens before initiating prescribed antimicrobials.
C. Allow for adequate rest.
D. Provide oral care.
F. Apply an additional blanket if the client feels chilled.

Question 50

ATI Textbook - Chapter 27

A nurse is checking the viral signs of a 92-year-old client. The client’s radial pulse has an irregular beat about every fifth or sixth beat. The rate is 92/min. The client is asymptomatic. The nurse should do which of the following?

A. Report the findings to the provider immediately
B. Place the client on telemetry.
C. Obtain an electrocardiogram.
D. Check an apical pulse for 60 seconds and note any pulse deficits.

Answer 50

D. Check an apical pulse for 60 seconds and note any pulse deficits.

Rationale:
This pulse does not require immediate medical treatment; therefore, the nurse should next measure the client’s apical pulse to assess the client’s status further. The nurse should then report the findings to the provider, who will then decide if the client requires telemetry and an electrocardiogram.

Question 51

ATI Textbook - Chapter 27

A nurse is checking the vital signs of a newly admitted client who has a fracture femur. the client’s BP is 140/94 mm Hg. The client denies any history of hypertensions. The nurse should do which of the following?

A. Ask the client if she is having pain.
B. Report the elevated BP to the provider.
C. Return in 30 min to recheck the BP.
D. Check the client’s orthostatic BP.

Answer 51

A. Ask the client if she is having pain.

Rationale:
This client has a broken femur, and her BP may be elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment. If the client’s BP is still elevated after pain interventions, the nurse should report his finding to the provider. This client needs further assessment at this time, so returning in 30 min is not appropriate. There is no indication for orthostatic pressures, and it might be difficult to have the client sit or stand with a fractured femur.

Question 52

ATI Textbook - Chapter 28

A client asks what her Snellen eye test results mean. Her acuity for both eyes together is 20/30. Which of the following is the appropriate response?

A. “You see at 20 ft what the normal-sighted person sees at 30 ft.”
B. “You see at 30 ft what the normal-sighted person sees at 20 ft.”
C. “You see at 10 ft what the normal-sighted person sees at 50 ft.”
D. “You see at 50 ft what the normal-sighted person sees at 20 ft.”

Answer 52

A. “You see at 20 ft what the normal-sighted person sees at 30 ft.”

Question 53

ATI Textbook - Chapter 28

A client with nystagmus will demonstrate

A. one eye gazing in a different direction during the cover/uncover test.
B. jerky eye movements during the six cardinal positions of gaze test.
C. droopy eyelids that partially or completely cover the pupil.
D. nicking of the retinal blood vessels during the internal eye examination.

Answer 53

B. jerky eye movements during the six cardinal positions of gaze test.

Rationale:

Question 54

ATI Textbook - Chapter 28

What part of the eye examination should occur first?

A. Extraocular movements
B. Internal structures
C. Visual acuity
D. Visual fields.

Answer 54

C. Visual acuity

Question 55

ATI Textbook - Chapter 29

The proper placement of the stethoscope for auscultating the aortic valve is the

A. second ICS just right of the sternum.
B. second ICS just left of the sternum.
C. fourth ICS just left of the sternum.
D. fifth ICS at the left midclavicular line.

Answer 55

A. second ICS just right of the sternum.

Question 56

ATI Textbook - Chapter 29

A nurse should perform the abdominal assessment using which of the following sequences?

A. Inspection, palpation, percussion, and auscultation
B. Auscultation, inspection, palpation, and percussion
C. Percussion, inspection, auscultation, and palpation
D. Inspection, auscultation, percussion, and palpation

Answer 56

D. Inspection, auscultation, percussion, and palpation

Question 57

ATI Textbook - Chapter 29

When performing percussion, which of the following sounds should be heard over most of the abdomen?

A. Dullness
B. Tympany
C. Grating
D. Gurgling

Answer 57

B. Tympany

Question 58

ATI Textbook - Chapter 30

When assessing a client’s skin temperature, the nurse should use which part of the hand?

A. Fingertips
B. Dorsal surface
C. Palmar surface
D. Base of the hand

Answer 58

B. Dorsal surface

Question 59

ATI Textbook - Chapter 30

Assessment of an older client reveals significant tenting of the skin over his forearm. Which of the following best explains this finding?

A. Loss of adipose tissue and elasticity.
B. Parchment-like skin
C. Significant flaking and dryness
D. skin tags

Answer 59

A. Loss of adipose tissue and elasticity.