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

1.

Which documentation best describes normal findings of nail assessment?

  • Nails concave, white, capillary refill 5 seconds
  • Nails brown, bulb like, capillary refill 5 seconds
  • Nails smooth, pink, capillary refill less than 2 seconds
  • Nails brittle with ridges, capillary refill 4 seconds

Explanation

Explanation
Correct Answer: C) Nails smooth, pink, capillary refill less than 2 seconds
Normal nail findings include smooth texture, pink coloration indicating adequate oxygenation and perfusion, and a capillary refill time of less than 2 seconds confirming good peripheral circulation. Concave nails suggest iron deficiency anemia. Brown discoloration may indicate fungal infection or systemic disease. Bulb-like or clubbing appearance suggests chronic hypoxia. Brittle nails with ridges indicate nutritional deficiencies or aging changes. A capillary refill greater than 2 seconds is abnormal and indicates poor peripheral perfusion.
2.

A nurse is assessing the integumentary system of a client during a physical examination. Which of the following findings obtained through palpation should the nurse identify as abnormal?

  • Skin that is cold and pale in appearance
  • Hair distribution on the arms and legs
  • Turgor that returns immediately after pinching the skin
  • Skin that is warm and dry to the touch

Explanation

Explanation
Correct Answer: A) Skin that is cold and pale in appearance
Normal skin findings on palpation include warmth, dryness, immediate turgor return, and normal hair distribution on the extremities. Skin that is cold and pale is an abnormal finding indicating poor peripheral perfusion, vasoconstriction, or circulatory compromise such as peripheral vascular disease, shock, or hypothermia. Hair distribution on the arms and legs is a normal finding. Immediate turgor return indicates good skin elasticity and hydration. Warm and dry skin is a normal expected finding during integumentary assessment.
3.

While assessing a client's neck, the nurse palpates the thyroid gland. Which is a normal finding?

  • Gland is easily visible without palpation
  • Gland is nodular, firm, and painful to palpation
  • Gland moves independently from swallowing
  • Gland is smooth, non-tender, and barely palpable

Explanation

Explanation
Correct Answer: D) Gland is smooth, non-tender, and barely palpable
The normal thyroid gland is small, smooth, non-tender, and barely palpable on physical examination. It moves upward with swallowing, which is a key characteristic used to confirm that the structure being palpated is indeed the thyroid. A thyroid gland that is easily visible without palpation indicates enlargement or goiter. A nodular, firm, and painful gland suggests thyroiditis, malignancy, or other pathology. A gland that moves independently from swallowing would suggest it is not the thyroid or that it is an abnormal mass.
4.

When assessing eye movement with the six cardinal fields of gaze, the nurse understands which of the following cranial nerves are being assessed?

  • Cranial nerves I, II, and IV

  • Cranial nerves I, II, and VII

  • Cranial nerves IV, V, and IX

  • Cranial nerves III, IV, and VI

Explanation

Explanation
Correct Answer: D) Cranial nerves III, IV, and VI
The six cardinal fields of gaze test the extraocular muscles and the three cranial nerves that control eye movement. Cranial Nerve III (Oculomotor) controls most eye movements including upward, downward, and medial gaze. Cranial Nerve IV (Trochlear) controls downward and inward eye movement. Cranial Nerve VI (Abducens) controls lateral or outward eye movement. Together these three nerves coordinate all directions of eye movement assessed during the six cardinal fields of gaze examination.
5.

A nurse is assessing pain in a pediatric client. Which pain assessment tool is most appropriate for the nurse to use?

  • Visual Analog Scale (VAS)
  • Numeric Rating Scale (NRS)
  • Wong-Baker FACES Scale
  • The Behavioral Pain Scale

Explanation

Explanation
Correct Answer: C) Wong-Baker FACES Scale
The Wong-Baker FACES Scale is the most appropriate pain assessment tool for pediatric clients as it uses a series of facial expressions ranging from happy to crying to represent increasing levels of pain. Children as young as 3 years old can point to the face that best matches how they feel, making it accessible and developmentally appropriate.
The Visual Analog Scale and Numeric Rating Scale require abstract thinking and numerical understanding, making them more suitable for adults or older children. The Behavioral Pain Scale is used for non-verbal or critically ill adult patients who cannot self-report pain.
6.

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

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.
7.

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

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.
8.

A nurse is assessing a client with painful, grouped vesicles on an erythematous base near their mouth. The client reports the lesions appeared after several days of stress. Which viral infection should the nurse suspect?

  • Herpes zoster

  • Warts (HPV)

  • Herpes varicella

  • Herpes simplex

Explanation

Explanation
Correct Answer: D) Herpes simplex
Herpes simplex virus type 1 (HSV-1) classically presents as painful grouped vesicles on an erythematous base located around the mouth, commonly known as cold sores or fever blisters. A hallmark feature of HSV-1 is that the virus remains dormant in the trigeminal nerve ganglia and reactivates during periods of physical or emotional stress, illness, or sun exposure. Herpes zoster follows a dermatomal pattern on the trunk or face. Warts caused by HPV are painless raised lesions. Herpes varicella presents as widespread scattered lesions across the entire body and is not triggered by stress.
9.

A nurse is assessing a client who reports dizziness. Which of the following actions should the nurse take to evaluate the client's balance?

  • Have the client bend over to assess the spine
  • Ask the client to squeeze both hands tightly
  • Have the client walk heel-to-toe in a straight line
  • Ask the client to shrug both shoulders

Explanation

Explanation
Correct Answer: C) Have the client walk heel-to-toe in a straight line
The heel-to-toe walk, also known as tandem gait, is a standard clinical test used to assess balance and coordination. It evaluates the integrity of the cerebellum and vestibular system, which are responsible for maintaining balance. A client with impaired balance will have difficulty maintaining a straight line during this maneuver. Bending over assesses spinal flexibility, hand squeezing tests grip strength and motor function, and shoulder shrugging assesses Cranial Nerve XI — none of which evaluate balance.
10.

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

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.

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