Health Assessment ATI EXAM 1
A nurse at a clinic is collecting data about pain from of a client who reports severe
abdominal pain. the nurse asks the client whether he has nausea and has been
vomiting. Which of the following pain characteristics is the nurse attempting to
determine?
A.Presence of associated manifestations
B.Location of the pain
C.Pain quality
D. aggravating and relieving factors - ansA
Rationale:
A. The nurse should attempt to identify manifestations that occur along with the clients
pain, such as nausea, fatigue or anxiety.
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 - ansC
Rationale:
C. The dorsal surface of the hand is the most sensitive to temperature.
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 - ansA, 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 in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect? (select all that apply.)
A. concave thoracic spine posteriorly
B. exaggerated lumbar curvature
C. concave lumbar spine posteriorly
D. exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side - ansC, E
Rationale:
C. The nurse should expect the client to have a concave lumbar spine posteriorly.
E. The nurse should expect the client to have muscle size equal on both sides or slightly
larger on the dominant side.
A nurse is assessing a client's neurosensory system. to evaluate stereognosis, the
nurse should ask the client to close his eyes and identify which of the following items?
A. a word she whispers 30 cm from his ear
B. a number she traces on the palm of his hand
C. the vibration of a tuning fork she places on his foot
D. a familiar object she places in his hand - ansD
Rationale:
D.Identifying a familiar object in the hand confirms the client's sense of stereognosis,
which is tactile recognition
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery
as a result of a motor vehicle crash. the surgeon tells the client that a blood transfusion
is essential. the client tells the nurse that based on his religious values and mandates,
he cannot receive a blood transfusion. Which of the following responses should the
nurse make?
A."i believe in this case you should really make an exception and accept the blood
transfusion."
B."i know your family would approve of your decision to have a blood transfusion."
C."Why does your religion mandate that you cannot receive any blood transfusions?"
,D."let's discuss the necessity for a blood transfusion with your religious and spiritual
leaders and come to a reasonable solution." - ansD
Rationale:
D. Involving the client's religious and spiritual leaders is a culturally responsive action at
this point. alternative forms of blood products can be discussed, and a plan reasonable
to all can be reached
A nurse is caring for a client who is concerned about his impending discharge to home
with a new colostomy because he is an avid swimmer. Which of the following
statements should the nurse make? (Select all that apply.)
A."You will do great! You just have to get used it."
B."Why are you worried about going home?"
C."Your daily routines will be different when you get home."
D."Tell me about your support system you'll have after you leave the hospital."
E."Let me tell you about a friend of mine with a colostomy who also enjoys swimming." -
ansC, D, E
Rationale:
C.presenting reality is an effective communication technique that can help the client
focus on what will really happen after the changes the surgery has made.
D. asking open-ended questions and offering general leads and broad opening
statements are effective communication techniques that encourage the client to express
feelings through dialogue and offer additional information.
E. offering self is an effective communication technique that can convey understanding
and share another's experience with the client. however, the nurse should return the
focus to the client as soon as she communicates the relevant point
A nurse is caring for a client who is crying while reading from his devotional book.
Which of the following interventions should the nurse take?
A.Contact the hospital's spiritual services.
B. ask him what is making him cry.
C. provide quiet times for these moments.
d. turn on the television for a distraction - ansC
Rationale:
C. Providing privacy and time for the reading of religious materials supports the client's
spiritual health.
, A nurse is caring for a client who is receiving morphine via a patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following
statements indicates that the client knows how to use the device?
A."i'll wait to use the device until it's absolutely necessary."
B."i'll be careful about pushing the button too much so idon't get an overdose."
C."i should tell the nurse if the pain doesn't stop while i am using this device."
D."i will ask my adult child to push the dose button when i am sleeping." - ansC
Rationale:
C. PCA allows the client to self-administer pain medication on an as-needed basis. if the
client is not achieving adequate pain control, he should let the nurse know so that she
can initiate a reevaluation of the client's pain management plan and possible dosage
change.
A nurse is caring for a client who reports pain with internal rotation of her right shoulder.
the nurse should identify that this discomfort can affect the client's ability to perform
which of the following activities?
A.Mopping her floors
B.Brushing the back of her hair
C.Fastening her bra behind her back
D. reaching into a cabinet above her sink - ansC
Rationale:
C. The client who is fastening a bra from behind requires internal rotation of the
shoulder, so this activity will elicit pain.
A nurse is caring for a client who shares the nurse's religious background. Which of the
following information should the nurse anticipate
A.Members of the same religion share similar feelings about their religion.
B. a shared religious background generates mutual regard for one another.
C. the same religious beliefs can influence individuals differently.
D. the nurse and client should discuss the differences and commonalities in their beliefs
- ansC
Rationale:
C.Members of any particular religion should be assessed for individual feelings and
ideas
A nurse is caring for a client who states, "i have to check with my wife and see if she
thinks i am ready to go home." The nurse replies, "how do you feel about going home
A nurse at a clinic is collecting data about pain from of a client who reports severe
abdominal pain. the nurse asks the client whether he has nausea and has been
vomiting. Which of the following pain characteristics is the nurse attempting to
determine?
A.Presence of associated manifestations
B.Location of the pain
C.Pain quality
D. aggravating and relieving factors - ansA
Rationale:
A. The nurse should attempt to identify manifestations that occur along with the clients
pain, such as nausea, fatigue or anxiety.
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 - ansC
Rationale:
C. The dorsal surface of the hand is the most sensitive to temperature.
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 - ansA, 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 in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect? (select all that apply.)
A. concave thoracic spine posteriorly
B. exaggerated lumbar curvature
C. concave lumbar spine posteriorly
D. exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side - ansC, E
Rationale:
C. The nurse should expect the client to have a concave lumbar spine posteriorly.
E. The nurse should expect the client to have muscle size equal on both sides or slightly
larger on the dominant side.
A nurse is assessing a client's neurosensory system. to evaluate stereognosis, the
nurse should ask the client to close his eyes and identify which of the following items?
A. a word she whispers 30 cm from his ear
B. a number she traces on the palm of his hand
C. the vibration of a tuning fork she places on his foot
D. a familiar object she places in his hand - ansD
Rationale:
D.Identifying a familiar object in the hand confirms the client's sense of stereognosis,
which is tactile recognition
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery
as a result of a motor vehicle crash. the surgeon tells the client that a blood transfusion
is essential. the client tells the nurse that based on his religious values and mandates,
he cannot receive a blood transfusion. Which of the following responses should the
nurse make?
A."i believe in this case you should really make an exception and accept the blood
transfusion."
B."i know your family would approve of your decision to have a blood transfusion."
C."Why does your religion mandate that you cannot receive any blood transfusions?"
,D."let's discuss the necessity for a blood transfusion with your religious and spiritual
leaders and come to a reasonable solution." - ansD
Rationale:
D. Involving the client's religious and spiritual leaders is a culturally responsive action at
this point. alternative forms of blood products can be discussed, and a plan reasonable
to all can be reached
A nurse is caring for a client who is concerned about his impending discharge to home
with a new colostomy because he is an avid swimmer. Which of the following
statements should the nurse make? (Select all that apply.)
A."You will do great! You just have to get used it."
B."Why are you worried about going home?"
C."Your daily routines will be different when you get home."
D."Tell me about your support system you'll have after you leave the hospital."
E."Let me tell you about a friend of mine with a colostomy who also enjoys swimming." -
ansC, D, E
Rationale:
C.presenting reality is an effective communication technique that can help the client
focus on what will really happen after the changes the surgery has made.
D. asking open-ended questions and offering general leads and broad opening
statements are effective communication techniques that encourage the client to express
feelings through dialogue and offer additional information.
E. offering self is an effective communication technique that can convey understanding
and share another's experience with the client. however, the nurse should return the
focus to the client as soon as she communicates the relevant point
A nurse is caring for a client who is crying while reading from his devotional book.
Which of the following interventions should the nurse take?
A.Contact the hospital's spiritual services.
B. ask him what is making him cry.
C. provide quiet times for these moments.
d. turn on the television for a distraction - ansC
Rationale:
C. Providing privacy and time for the reading of religious materials supports the client's
spiritual health.
, A nurse is caring for a client who is receiving morphine via a patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following
statements indicates that the client knows how to use the device?
A."i'll wait to use the device until it's absolutely necessary."
B."i'll be careful about pushing the button too much so idon't get an overdose."
C."i should tell the nurse if the pain doesn't stop while i am using this device."
D."i will ask my adult child to push the dose button when i am sleeping." - ansC
Rationale:
C. PCA allows the client to self-administer pain medication on an as-needed basis. if the
client is not achieving adequate pain control, he should let the nurse know so that she
can initiate a reevaluation of the client's pain management plan and possible dosage
change.
A nurse is caring for a client who reports pain with internal rotation of her right shoulder.
the nurse should identify that this discomfort can affect the client's ability to perform
which of the following activities?
A.Mopping her floors
B.Brushing the back of her hair
C.Fastening her bra behind her back
D. reaching into a cabinet above her sink - ansC
Rationale:
C. The client who is fastening a bra from behind requires internal rotation of the
shoulder, so this activity will elicit pain.
A nurse is caring for a client who shares the nurse's religious background. Which of the
following information should the nurse anticipate
A.Members of the same religion share similar feelings about their religion.
B. a shared religious background generates mutual regard for one another.
C. the same religious beliefs can influence individuals differently.
D. the nurse and client should discuss the differences and commonalities in their beliefs
- ansC
Rationale:
C.Members of any particular religion should be assessed for individual feelings and
ideas
A nurse is caring for a client who states, "i have to check with my wife and see if she
thinks i am ready to go home." The nurse replies, "how do you feel about going home
