Unit XVIII - Health Assessment Flashcards
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.
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.
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
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.
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
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.
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.
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.
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
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.
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
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.
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
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.
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
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
C. Use books and other visual aids to advance the interview.
Rationale:
This technique is very useful for working with school-age children.
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.
C. Perform the cover-uncover test.
Rationale:
This test identifies whether a child has strabismus, or nonbinocular vision.
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.
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.
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.
B. Place your hand under mine.
Rationale:
Allowing the child to touch her abdomen during the examination will promote relaxation.
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.
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.
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.
C. bend forward with the knees straight and the arms dangling.
Rationale:
This position allows for adequate visualization of any asymmetry.
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.
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.
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.”
D. “Regular heart rate and rhythm: S1, S2 heard.”
Rationale:
This clear, concise charting for normal heart sounds.
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.
A. describe the symptoms.
Rationale:
Preschoolers are usually able to describe symptoms of their problem.
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
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.
