ATI Custom ASN Physical Assessment NSG1530 Final Winter

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Free ATI Custom ASN Physical Assessment NSG1530 Final Winter Questions

1.

A nurse is teaching a client about monthly self-breast examinations. Which technique should the nurse recommend?

  • Assess quarterly (every 3 months)
  • Examining only the right breast unless symptoms occur
  • Using the palms to press deeply into breast tissue
  • Lifting arms overhead to inspect for skin retraction

Explanation

Explanation
Correct Answer: D) Lifting arms overhead to inspect for skin retraction
Lifting the arms overhead during breast self-examination is a key inspection technique that helps reveal skin retraction, dimpling, or asymmetry that may not be visible with arms at rest. These changes can be early visual indicators of an underlying breast mass pulling on the surrounding tissue, making this an important step in the self-examination process.
2.

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.

3.

A nurse observes an older adult client with multiple bruises of varying ages and inconsistencies between the client's explanation and the injuries. How should the nurse prioritize the next step in care?

  • Document the injuries and history in the chart but continue routine care without further action unless new symptoms appear
  • Administer prescribed pain medications to manage pain and reassess the symptoms in 24 hours
  • Encourage the client to discuss the injuries with family members before taking any clinical action
  • Report the findings to the healthcare provider and initiate an elder abuse assessment tool to gather more information

Explanation

Explanation
Correct Answer: D) Report the findings to the healthcare provider and initiate an elder abuse assessment tool to gather more information
Multiple bruises of varying ages combined with inconsistent explanations are classic red flags for elder abuse. Nurses are mandated reporters and are ethically and legally obligated to report suspected abuse immediately. Initiating a validated elder abuse assessment tool ensures a thorough, structured evaluation. Delaying action, managing only pain, or involving family members before reporting could compromise the client's safety and is not appropriate clinical prioritization.
4.

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?

  • The client is exhibiting signs of lethargy.
  • The client shows signs of hyperventilation.
  • The client demonstrates signs of respiratory distress.
  • The client has normal breathing patterns.

Explanation

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.
5.

A client states they have been having black tarry stools. How should the nurse document this finding?

  • Steatorrhea
  • Clay colored stool
  • Melena
  • Hematochezia

Explanation

Explanation
Correct Answer: C) Melena
Melena is the correct medical term for black, tarry, foul-smelling stools caused by the digestion of blood in the gastrointestinal tract. It typically indicates upper GI bleeding — such as from a peptic ulcer or esophageal varices — where blood is broken down by digestive enzymes as it travels through the intestines, producing the characteristic dark, tarry appearance. Accurate documentation using the correct terminology ensures clear clinical communication and appropriate follow-up.
6.

A nurse is auscultating a client's heart sounds and hears a "swooshing" sound between the normal heart sounds. How should the nurse interpret this finding?

  • The client has diminished heart sounds
  • The client has a heart murmur
  • The client has a pericardial friction rub
  • The client has a pleural effusion

Explanation

Explanation
Correct Answer: B) The client has a heart murmur
A heart murmur is characterized by a swooshing or blowing sound heard between the normal S1 and S2 heart sounds, caused by turbulent blood flow through the heart valves. This turbulence may result from valve stenosis, regurgitation, or increased blood flow across a normal valve. Murmurs are graded on a scale of I to VI based on intensity and require further evaluation to determine their clinical significance.
7.

A nurse is palpating the chest wall of a client after chest trauma and feels a crackling sensation under the skin. The nurse documents this finding as crepitus. Which description correctly defines crepitus?

  • A popping sensation under the skin caused by joint or cartilage inflammation in the thorax.
  • A coarse vibration felt over the chest wall caused by fluid accumulation in the pleural space.
  • A crackling sensation felt under the skin caused by air leaking into the subcutaneous tissue.
  • A grating sensation over the lung fields caused by friction between inflamed pleural surfaces.

Explanation

Explanation
Correct Answer: C) A crackling sensation felt under the skin caused by air leaking into the subcutaneous tissue.
Subcutaneous crepitus occurs when air escapes into the subcutaneous tissue, typically following chest trauma, pneumothorax, or surgical procedures. The trapped air creates a characteristic crackling or bubbling sensation when the skin is palpated, similar to the feeling of bubble wrap being compressed. It is a significant finding that warrants immediate assessment for underlying pneumothorax or airway injury.
8.

Convert 8 ounces (oz) to milliliters (mL).

Explanation

Explanation
Correct Answer: 240 mL
The standard conversion is 1 ounce = 30 mL. Therefore:
9.

A nurse is trying to assess a client's nutritional status. Which of the following methods is the most accurate method to assess the dietary intake of the client?

  • List of typical dinner items.
  • List of foods eaten over the past 24-hours.
  • Discussion of favorite foods.
  • Calculation of Body Mass Index (BMI).

Explanation

Explanation
Correct Answer: B) List of foods eaten over the past 24-hours.
The 24-hour dietary recall is the most widely used and clinically accurate method for assessing a client's actual dietary intake. It captures a specific, recent, and detailed account of everything the client consumed, allowing the nurse to evaluate caloric intake, nutrient balance, meal patterns, and identify potential deficiencies. It is more reflective of actual eating habits than discussing favorites or typical meals.
10.

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?

  • Romberg's Test
  • Braden Scale
  • Glasgow Coma Scale
  • Weber Test

Explanation

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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