ATI Custom ASN Physical Assessment NSG1530 Final Winter
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Free ATI Custom ASN Physical Assessment NSG1530 Final Winter Questions
A nurse is caring for a bedbound client who has limited mobility and is incontinent of urine. Which factors increase this client's risk for developing a pressure injury? (Select All That Apply)
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Use of a pressure-relieving mattress
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Moisture from incontinence
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Immobility
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Friction and shearing
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Adequate protein intake
Explanation
Correct Answers: B) Moisture from incontinence, C) Immobility, D) Friction and shearing
Moisture from incontinence breaks down skin integrity and increases susceptibility to pressure injury. Immobility prevents the client from repositioning, causing sustained pressure over bony prominences that restricts blood flow. Friction and shearing damage the skin and underlying tissue when the client is moved or slides in bed. A pressure-relieving mattress actually reduces risk, and adequate protein intake supports tissue repair and skin integrity — both are protective factors, not risk factors.
A nurse inspects a client's respiratory effort during a routine assessment. The client is sitting upright and breathing through pursed lips. The nurse also observes nasal flaring and use of accessory muscles during inhalation. Which interpretation should the nurse make based on these findings?
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The client is exhibiting signs of lethargy.
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The client shows signs of hyperventilation.
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The client demonstrates signs of respiratory distress.
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The client has normal breathing patterns.
Explanation
Correct Answer: C) The client demonstrates signs of respiratory distress.
Pursed-lip breathing, nasal flaring, and accessory muscle use (such as the sternocleidomastoid and scalene muscles) are classic visual indicators of respiratory distress. These compensatory mechanisms indicate the client is working harder than normal to breathe, suggesting inadequate oxygenation or ventilation. This warrants immediate further assessment including oxygen saturation, respiratory rate, and prompt provider notification.
A nurse assesses a client with chronic obstructive pulmonary disease (COPD). The client's respiratory rate is 24 breaths/min, oxygen saturation is 87% on room air, and the client appears fatigued with shallow breathing. Which priority action should the nurse take?
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Instruct the client to limit talking during the assessment.
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Encourage the client to lie flat and rest.
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Instruct the client to ambulate across the room.
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Elevate the head of the bed and apply oxygen as prescribed.
Explanation
Correct Answer: D) Elevate the head of the bed and apply oxygen as prescribed.
With an oxygen saturation of 87% and a respiratory rate of 24 breaths/min, this client is experiencing hypoxemia and respiratory distress. Elevating the head of the bed to 45–90 degrees maximizes diaphragmatic excursion and lung expansion, reducing the work of breathing. Applying supplemental oxygen as prescribed directly addresses the dangerously low oxygen saturation. In COPD, oxygen is carefully titrated, but an SpO₂ of 87% requires immediate intervention — airway and oxygenation always take priority using the ABC framework.
2 tsp × 5 mL = 10 mL
Explanation
This conversion is commonly used in clinical practice when measuring and administering liquid medications, particularly in pediatric and home care settings where household measurements are often used by clients.
A nurse is caring for a client who has cognitive impairment and is unable to verbally express pain. The nurse needs to select an appropriate pain assessment tool to evaluate the client's level of discomfort. Which pain scale is most appropriate for this client?
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Visual Analog Scale
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Numeric Rating Scale (0–10)
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Neonatal Infant Pain Scale (NIPS)
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FLACC Scale
Explanation
Correct Answer: D) FLACC Scale
The FLACC scale — which stands for Face, Legs, Activity, Cry, and Consolability — is a behavioral pain assessment tool designed for clients who cannot verbally communicate their pain, including those with cognitive impairment. The nurse observes and scores five behavioral indicators to estimate the client's pain level. It is particularly valuable because it does not require any verbal response from the client, making it the most appropriate choice in this scenario.
A nurse is assessing a client's cranial nerves during a head and neck examination. Which of the following actions demonstrates proper assessment of cranial nerve XI?
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Instructing the client to shrug their shoulders against resistance
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Having the client close their eyes and identify a familiar scent
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Asking the client to smile and raise their eyebrows
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Placing a cotton ball on the client's face to assess light touch
Explanation
Correct Answer: A) Instructing the client to shrug their shoulders against resistance
Cranial nerve XI is the Spinal Accessory nerve, which controls the sternocleidomastoid and trapezius muscles. It is assessed by asking the client to shrug their shoulders and turn their head against the nurse's resistance. Identifying a scent tests CN I (Olfactory), smiling and raising eyebrows tests CN VII (Facial), and light touch on the face tests CN V (Trigeminal).
A nurse is assigned to measure the temperature of a client who reports chills and sweating. The nurse uses a tympanic thermometer and obtains a reading of 101.3°F (38.5°C). Which action should the nurse take next?
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Retake the temperature using the oral method.
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Administer acetaminophen without provider order.
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Apply a cool compress and reassess in 2 hours.
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Document the temperature and recheck in one hour.
Explanation
Correct Answer: D) Document the temperature and recheck in one hour.
A temperature of 101.3°F (38.5°C) confirms a low-grade fever. The tympanic method is a validated and reliable measurement route, so retaking it is unnecessary. The nurse should accurately document the finding, continue monitoring the client's temperature trend, assess for other signs of infection, ensure adequate hydration, and notify the provider if the fever persists, worsens, or is accompanied by other concerning symptoms. Administering medication without an order violates scope of practice.
A nurse assesses a client who is disoriented to time and place. Which finding should the nurse evaluate as a potential contributing factor?
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Use of antihypertensive medication.
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History of recent head injury.
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Elevated blood glucose level.
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Report of chronic back pain.
Explanation
Correct Answer: B) History of recent head injury.
A recent head injury is the most direct and clinically significant potential contributing factor to disorientation to time and place. Head trauma can cause concussion, intracranial bleeding, increased intracranial pressure, or diffuse axonal injury, all of which directly impair the brain's ability to process and orient to person, place, and time. This finding requires urgent neurological assessment and must be prioritized given its immediate life-threatening implications.
During a respiratory assessment, a nurse assesses increased tactile fremitus over the right lung. Which action should the nurse take next?
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Document this finding as normal.
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Encourage bedrest.
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Notify the healthcare provider of possible lung consolidation.
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Ask the client if they have recently consumed a large meal.
Explanation
Correct Answer: C) Notify the healthcare provider of possible lung consolidation.
Increased tactile fremitus occurs when vibrations transmitted through the chest wall are enhanced, which happens when air in the lungs is replaced by denser material such as fluid or consolidated tissue. This is a hallmark sign of pneumonia or lung consolidation. Since this is an abnormal finding requiring medical diagnosis and treatment, the nurse must promptly notify the healthcare provider for further evaluation such as a chest X-ray.
A nurse is assessing a client who reports perineal pain and difficulty sitting. Inspection reveals redness, swelling, and a small area of purulent drainage near the anus. Which condition is the client most likely experiencing?
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Pressure ulcer
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Rectal polyp
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Hemorrhoid
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Perianal abscess
Explanation
Correct Answer: D) Perianal abscess
A perianal abscess is a localized collection of pus in the tissue around the anus, presenting with perineal pain, difficulty sitting, localized swelling, redness, and purulent drainage — all of which match this client's presentation. Hemorrhoids present as painless or mildly painful swollen veins without purulent drainage, rectal polyps are typically asymptomatic, and pressure ulcers develop from prolonged pressure over bony prominences.
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