ATI ASN Physical Assessment NSG1530 Foundational Physical Assessment Exam 2 .
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Free ATI ASN Physical Assessment NSG1530 Foundational Physical Assessment Exam 2 . Questions
A student nurse asks what PERRLA stands for. Which answer by the nurse demonstrates the correct explanation of PERRLA?
- Pupils are Elevated and Round and Red to Link and Association
- Pupils are Extended and Round and Responsive to Lactic and Application
- Pupils are Edged and Round and Raised to Lacunar and Activation
- Pupils are Equal and Round and React to Light and Accommodate
Explanation
Correct Answer: D) Pupils are Equal and Round and React to Light and Accommodate
PERRLA is a standard acronym used in neurological and eye assessments to document normal pupil findings. Each letter represents a specific characteristic: Pupils are Equal in size, Round in shape, and Reactive to Light — meaning they constrict when light is shone into them — and Accommodate — meaning they constrict when focusing on a near object. This assessment is critical in evaluating the function of Cranial Nerve III and detecting neurological changes such as increased intracranial pressure or brain herniation.
A nurse notes that her client has an area of intact, red skin that does not blanch with fingertip pressure. Which pressure ulcer stage should the nurse document?
- Stage I
- Stage IV
- Stage II
- Stage III
Explanation
Correct Answer: A) Stage I
A Stage I pressure ulcer is characterized by intact, non-blanchable erythema of a localized area, typically over a bony prominence. The skin is unbroken but appears red and does not blanch when fingertip pressure is applied, indicating that the underlying capillaries are damaged and there is early tissue injury. Stage II involves partial thickness skin loss. Stage III involves full thickness skin loss without exposed bone. Stage IV involves full thickness tissue loss with exposed bone, tendon, or muscle.
A nurse is completing a head and neck assessment on a client. The nurse observes asymmetry of the face when the client smiles and frowns. The client also reports decreased sensation to light touch on the left cheek. Palpation reveals supraclavicular lymph nodes that are firm, non-tender, fixed, and measure approximately 1.5 cm. Which action should the nurse take next?
- Reassess the client's facial symmetry after providing rest
- Notify the health care provider of the abnormal findings
- Continue with the remaining physical assessment
- Document the findings as normal variations.
Explanation
Correct Answer: B) Notify the health care provider of the abnormal findings
The combination of findings presented are significantly abnormal and require prompt notification of the healthcare provider. Facial asymmetry suggests Cranial Nerve VII dysfunction. Decreased sensation on the cheek indicates Cranial Nerve V impairment. Most critically, supraclavicular lymph nodes that are firm, fixed, non-tender, and greater than 1 cm in size are classic characteristics of malignant lymphadenopathy, which may indicate metastatic cancer or lymphoma. These findings together constitute an urgent clinical situation that must be escalated to the provider immediately rather than documented as normal or deferred.
A nurse is performing a physical assessment on a client and begins the eye assessment. Which of the following findings during the eye exam would require further follow-up?
- Loss of peripheral vision in the left eye
- Conjunctiva pink and moist
- Symmetrical corneal light reflex
- Pupils equal and reactive to light
Explanation
Correct Answer: A) Loss of peripheral vision in the left eye
Loss of peripheral vision is an abnormal finding that requires immediate further follow-up as it may indicate serious conditions such as glaucoma, retinal detachment, or a neurological lesion affecting the visual pathways. Pink and moist conjunctiva, symmetrical corneal light reflex, and pupils that are equal and reactive to light are all normal expected findings during an eye assessment and do not require further investigation.
A nurse is assessing for cyanosis on a client with darker pigmented skin. Which area provides the best site for evaluation?
- Oral mucosa
- Ears
- Abdomen
- Palms of the hands
Explanation
Correct Answer: A) Oral mucosa
In clients with darker pigmented skin, cyanosis cannot be reliably detected by examining the skin surface as melanin masks color changes. The oral mucosa, particularly the lips and gums, contains less melanin and has highly vascularized tissue close to the surface, making it the most reliable site to detect the bluish discoloration of cyanosis regardless of skin tone. The conjunctiva and nail beds are also acceptable alternative sites.
A nurse is assessing a client who reports recurrent headaches. Which of the following are common characteristics of migraines? (Select All that Apply.)
- Aura, such as visual disturbances
- Nausea and vomiting
- Lasts up to 72 hours
- Sudden loss of consciousness
- Photophobia
Explanation
Correct Answer: A) Aura such as visual disturbances, B) Nausea and vomiting, C) Lasts up to 72 hours, E) Photophobia
Migraines are a complex neurological condition with well-established characteristics. An aura, which commonly presents as visual disturbances such as flashing lights or blind spots, occurs in approximately one-third of migraine sufferers before the headache begins. Nausea and vomiting are hallmark accompanying symptoms.
Migraines typically last between 4 to 72 hours if untreated. Photophobia, or sensitivity to light, along with phonophobia are classic features that distinguish migraines from other headache types. Sudden loss of consciousness is not a characteristic of migraines and would instead suggest a seizure or syncopal episode requiring urgent evaluation.
The nurse is assessing the client's olfactory nerve (cranial nerve I). What action would the nurse take?
- Romberg's test
- Smelling test
- Visual acuity test
- Whisper test
Explanation
Correct Answer: B) Smelling test
Cranial Nerve I, the Olfactory nerve, is solely responsible for the sense of smell. To assess its function, the nurse asks the client to close their eyes and identify familiar scents such as coffee, vanilla, or cinnamon presented under each nostril separately. An inability to identify scents may indicate anosmia, which can result from nasal obstruction, head trauma, or neurological conditions. The Romberg test assesses balance and proprioception, visual acuity tests Cranial Nerve II, and the whisper test assesses hearing function related to Cranial Nerve VIII.
A nurse is assessing a client and notes a pill-rolling tremor, shuffling gait, and bradykinesia. Which condition is this client most likely experiencing?
- Parkinson's Disease
- Cerebellar ataxia
- Multiple Sclerosis
- Huntington's Disease
Explanation
Correct Answer: A) Parkinson's Disease
The triad of pill-rolling tremor, shuffling gait, and bradykinesia — meaning slowness of movement — are the classic hallmark features of Parkinson's Disease. This progressive neurodegenerative disorder results from the loss of dopamine-producing neurons in the substantia nigra of the brain. The pill-rolling tremor occurs at rest and is highly specific to Parkinson's Disease.
The shuffling gait with small steps and reduced arm swing, combined with bradykinesia and postural instability, collectively form the cardinal motor features of this condition. Cerebellar ataxia presents with wide-based unsteady gait. Multiple Sclerosis presents with variable neurological symptoms including spasticity and visual changes. Huntington's Disease presents with chorea — involuntary jerky dance-like movements — not tremor or bradykinesia.
Which action should the nurse take when assessing skin turgor in an older adult client?
- Press the skin over the shin for edema
- Pinch the back of the hand and observe the recoil
- Use the back of the hand to check for warmth
- Gently lift the skin over the clavicle
Explanation
Correct Answer: D) Gently lift the skin over the clavicle
In older adult clients, skin turgor should be assessed over the clavicle or sternum rather than the back of the hand or forearm. This is because older adults naturally experience a loss of skin elasticity and subcutaneous tissue due to aging, causing the skin on the hands and forearms to tent regardless of hydration status, making those sites unreliable for turgor assessment.
The skin over the clavicle retains its elasticity longer and provides a more accurate reflection of the client's true hydration status. Pressing the shin assesses for edema, not turgor. Using the back of the hand checks for temperature, not turgor.
A nurse is assessing a client's mental health status. Which question best evaluates the client's self-concept?
- "How satisfied are you with your relationships with people?"
- "Have you ever been treated for mental health problems?"
- "Have you had any recent changes in your life?"
- "How would you describe yourself to others?"
Explanation
Correct Answer: D) "How would you describe yourself to others?"
Self-concept refers to how an individual perceives and defines themselves, including their beliefs, values, roles, and identity. Asking the client how they would describe themselves to others directly elicits information about their self-image, self-worth, and personal identity, making it the most appropriate question for evaluating self-concept. Option A assesses interpersonal relationships and social support. Option B explores past psychiatric history. Option C assesses life stressors and coping, none of which specifically target the client's self-concept.
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