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 performing an assessment on an adolescent male. The nurse identifies unexpected enlargement of the male breasts. Which of the following terms should be used to document this finding?
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Mammogram.
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Mastitis.
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Mastectomy.
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Gynecomastia.
Explanation
Correct Answer: D) Gynecomastia.
Gynecomastia is the medical term for the benign enlargement of breast tissue in males. It commonly occurs during adolescence due to temporary hormonal imbalances between estrogen and testosterone during puberty. While often self-resolving, it should be documented accurately and monitored, as it can also be associated with medications, liver disease, or hormonal disorders in some cases.
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 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 is palpating a client's radial pulse during a cardiovascular assessment and notates irregularity. What action should the nurse take next?
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Document the sound as a physiologic S3
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Document as a normal finding
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Notify provider
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Auscultate the apical pulse for a full minute
Explanation
Correct Answer: D) Auscultate the apical pulse for a full minute
When an irregular radial pulse is detected, the next step is to auscultate the apical pulse at the apex of the heart for a full minute to obtain a more accurate heart rate and assess the rhythm further. This also allows the nurse to check for a pulse deficit. An irregular pulse is not a normal finding and should not be documented as such. Notifying the provider comes after completing a thorough assessment, and S3 is a heart sound finding — not related to pulse irregularity.
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.
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.
Convert 2 teaspoons (tsp) to milliliters (mL).
Explanation
Correct Answer: 10 mL
The standard conversion is 1 teaspoon = 5 mL. Therefore:
5 g × 1,000 = 500 mg
This gram-to-milligram conversion is one of the most frequently used calculations in clinical pharmacology, as many medications are prescribed in grams but dispensed in milligrams.
A nurse is assessing a client's nutritional status. The nurse notes hypopigmented hair and abdominal edema. Which of the following nutrient deficiencies would the nurse anticipate the client is experiencing from these findings?
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Calcium
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Fats
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Carbohydrates
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Protein
Explanation
Correct Answer: D) Protein
Hypopigmented (lighter than normal) hair and abdominal edema (ascites) are classic signs of severe protein deficiency, a condition known as Kwashiorkor. Protein is essential for maintaining oncotic pressure in the blood vessels — when severely depleted, fluid leaks into the abdominal cavity causing edema. Hair loses its pigmentation and becomes thin and brittle due to lack of amino acids needed for melanin and keratin production.
A nurse is preparing to assess a client's orientation and neurologic status. Which of the following should the nurse use to gather this information?
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Romberg's Test
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Braden Scale
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Glasgow Coma Scale
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Weber Test
Explanation
Correct Answer: C) Glasgow Coma Scale
The Glasgow Coma Scale (GCS) assesses a client's level of consciousness and neurologic status by evaluating eye opening, verbal response, and motor response — making it the appropriate tool for orientation and neurologic assessment. The Romberg test assesses balance and proprioception, the Braden Scale assesses pressure injury risk, and the Weber test evaluates hearing lateralization.
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