ATI Custom ASN Physical Assessment NSG1530 Final Winter
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Free ATI Custom ASN Physical Assessment NSG1530 Final Winter Questions
A nurse asks a client to perform the Romberg test. Which instruction should the nurse give?
- A) Stand with your feet together and close your eyes
- B) Raise one leg and hop in place
- C) Walk heel to toe in a straight line
- D) Bend over and touch your toes
Explanation
Correct Answer: A) Stand with your feet together and close your eyes
The Romberg test assesses balance and proprioception by having the client stand with feet together and eyes closed. A positive Romberg sign — excessive swaying or loss of balance — indicates impaired proprioception or cerebellar dysfunction. Walking heel to toe assesses coordination (tandem gait), hopping assesses motor strength, and bending to touch toes assesses flexibility — none of which are the Romberg test.
Complete the following sentence by using the drop down options.
A nurse notes that a client's skin is pale and clammy. This is objective data. The client then reports, "I feel very anxious." This is subjective data.
Explanation
Correct Answers: Objective / Subjective
Pale and clammy skin is objective data because it is directly observable and measurable by the nurse without the client having to report it. The client stating "I feel very anxious" is subjective data because it is based solely on what the client reports and cannot be directly measured or observed by the nurse. Distinguishing between subjective and objective data is fundamental to accurate nursing assessment and documentation.
Which of the following assessments indicates a client may be dehydrated?
- A) Moist mucous membranes
- B) Heart rate of 75 beats per minute
- C) Tenting of the skin over the clavicle
- D) Clear yellow urine
Explanation
Correct Answer: C) Tenting of the skin over the clavicle
Skin tenting — where the skin is pinched and slowly returns to its normal position — is a classic sign of dehydration and decreased skin turgor. It is best assessed over the clavicle or sternum in older adults, as these areas are less affected by age-related skin changes. When the body is dehydrated, skin loses its elasticity due to reduced fluid in the interstitial tissues, causing it to remain "tented" after being pinched rather than snapping back immediately.
22 ÷ 2.2 = 10 kg
Explanation
This conversion formula (lbs ÷ 2.2 = kg) is essential in clinical practice as many medication doses, particularly in pediatrics, are calculated based on the client's weight in kilograms
A nurse is assessing a client newly diagnosed with gout. Which of the following questions should the nurse include in the assessment to identify the common causes of gout?
- A) "Do you have a history of asthma?"
- B) "Do you eat foods that are high in carbohydrates?"
- C) "Do you eat a lot of red meat in your diet?"
- D) "Do you have a history of arthritis?"
Explanation
Correct Answer: C) "Do you eat a lot of red meat in your diet?"
Gout is caused by hyperuricemia — an excess of uric acid in the blood — which leads to the deposition of monosodium urate crystals in the joints. Red meat is high in purines, which are broken down into uric acid during metabolism. A diet rich in red meat, organ meats, shellfish, and alcohol significantly increases uric acid levels and is a primary dietary contributor to gout. Assessing dietary habits is therefore a critical component of the gout history.
A nurse assesses a client's cranial nerves during a head-to-toe exam. The client follows the nurse's finger in six cardinal directions. Which cranial nerves is the nurse assessing with this technique?
- A) Cranial nerves V and VII
- B) Cranial nerves IX and X
- C) Cranial nerves III, IV, and VI
- D) Cranial nerves I and II
Explanation
Correct Answer: C) Cranial nerves III, IV, and VI
The six cardinal fields of gaze test assesses the extraocular muscles controlled by cranial nerve III (Oculomotor), CN IV (Trochlear), and CN VI (Abducens). These three nerves work together to control all directions of eye movement. Having the client follow a finger through six directions allows the nurse to evaluate the function of each nerve and detect any weakness or paralysis in eye movement.
A nurse is teaching a client about healthy body mass index (BMI) ranges during a wellness visit. Which BMI range should the nurse identify as normal?
- A) 18.5–24.9
- B) 35–39.9
- C) 25–29.9
- D) Less than 18.5
Explanation
Correct Answer: A) 18.5–24.9
A BMI of 18.5–24.9 is classified as normal or healthy weight. A BMI below 18.5 indicates underweight, 25–29.9 is classified as overweight, and 35–39.9 falls within the obese range (Class II obesity). BMI is a widely used screening tool to assess whether a client's weight is appropriate for their height.
A nurse obtains a blood pressure reading of 160/100 mmHg on a client with a history of hypertension. The client denies headache or dizziness. The nurse notes the cuff was too small for the client's upper arm. Which interpretation is most appropriate?
- A) The reading may be falsely elevated due to cuff size
- B) The client is experiencing a hypertensive emergency
- C) The client's blood pressure is within expected range
- D) The client is at risk for orthostatic hypotension
Explanation
Correct Answer: A) The reading may be falsely elevated due to cuff size
Using a blood pressure cuff that is too small for the client's arm is a well-documented source of measurement error that produces falsely elevated readings. Accurate blood pressure assessment requires proper cuff sizing — the bladder should encircle at least 80% of the arm. Since the nurse identified this technical error and the client is asymptomatic, the most appropriate interpretation is that the reading may not be accurate before escalating to a hypertensive emergency diagnosis.
8 oz × 30 mL = 240 mL
Explanation
This conversion is commonly used in clinical practice for measuring fluid intake and output, particularly when clients consume beverages measured in ounces, which must be recorded in milliliters for accurate fluid balance monitoring.
A nurse assesses a client who is disoriented to time and place. Which finding should the nurse evaluate as a potential contributing factor?
- A) Use of antihypertensive medication.
- B) History of recent head injury.
- C) Elevated blood glucose level.
- D) 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.
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