ATI Custom ASN Physical Assessment NSG1530 Final Winter
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Free ATI Custom ASN Physical Assessment NSG1530 Final Winter Questions
Convert 8 ounces (oz) to milliliters (mL).
Explanation
Correct Answer: 240 mL
The standard conversion is 1 ounce = 30 mL. Therefore:
A nurse is performing a vision assessment on a client during a physical exam. Which test is used to assess visual acuity?
- Confrontation test
- Six cardinal fields of gaze
- PERRLA assessment
- Snellen chart test
Explanation
Correct Answer: D) Snellen chart test
The Snellen chart is the standardized tool used to measure visual acuity by having the client read progressively smaller letters from a distance of 20 feet. The confrontation test assesses peripheral vision, the six cardinal fields of gaze evaluate extraocular muscle function, and PERRLA assesses pupillary response to light — none of which measure visual acuity.
A nurse auscultates the lungs of a client who reports shortness of breath. Breath sounds are diminished in the lower lobes, and the nurse hears fine crackles at the end of inspiration. Which do these findings most likely indicate?
- Bronchial obstruction.
- Pneumothorax.
- Normal age-related change.
- Pulmonary edema.
Explanation
Correct Answer: D) Pulmonary edema.
Fine crackles (rales) heard at the end of inspiration, combined with diminished breath sounds in the lower lobes and shortness of breath, are classic auscultatory findings of pulmonary edema. In pulmonary edema, fluid accumulates in the alveoli and small airways, producing the characteristic fine crackling sound as fluid-filled alveoli pop open during late inspiration. The lower lobes are affected first due to gravity-dependent fluid pooling. This is a serious finding requiring immediate nursing intervention and provider notification.
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
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.
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?
- Calcium
- Fats
- Carbohydrates
- 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 perform a head-to-toe physical assessment on a newly admitted client. The nurse begins the assessment using inspection. Which action demonstrates correct use of inspection?
- Observing the client's skin for color, moisture, and lesions
- Percussing the abdomen to assess for tympany
- Assess abdomen for tenderness
- Listening for bowel sounds
Explanation
Correct Answer: A) Observing the client's skin for color, moisture, and lesions
Inspection is the deliberate, systematic visual examination of the client using the nurse's eyes and occasionally a penlight. Observing the skin for color, moisture, and lesions is a direct application of this technique. Percussion involves tapping to assess underlying structures, palpation is used to assess for tenderness, and auscultation involves listening with a stethoscope — all of which are separate and distinct assessment techniques.
Which of the following is a clinical manifestation of a urinary tract infection?
- Odorless urine
- Clear urine
- Abdominal distention
- Dysuria
Explanation
Correct Answer: D) Dysuria
Dysuria, which is painful or burning urination, is a hallmark clinical manifestation of a urinary tract infection. It occurs due to inflammation and irritation of the urothelium caused by bacterial invasion. Other classic UTI symptoms include frequency, urgency, cloudy or foul-smelling urine, and hematuria — making odorless and clear urine inconsistent with a UTI, and abdominal distention unrelated to the condition.
Convert 2 teaspoons (tsp) to milliliters (mL).
Explanation
Correct Answer: 10 mL
The standard conversion is 1 teaspoon = 5 mL. Therefore:
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?
- Instructing the client to shrug their shoulders against resistance
- Having the client close their eyes and identify a familiar scent
- Asking the client to smile and raise their eyebrows
- 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 inspects a client's lower extremities and notes swelling and redness. Which assessment technique should the nurse perform next?
- Inspection.
- Palpation.
- Percussion.
- Auscultation.
Explanation
Correct Answer: B) Palpation.
After inspecting and identifying swelling and redness in the lower extremities, the logical next step in the physical assessment sequence is palpation. Palpating the affected area allows the nurse to assess for warmth, tenderness, texture, edema pitting, and cord-like structures that may indicate deep vein thrombosis (DVT), cellulitis, or lymphedema. Palpation provides critical tactile data that inspection alone cannot reveal.
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