ATI Health Assessment Exam 3 - Arizona College of Nursing
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Free ATI Health Assessment Exam 3 - Arizona College of Nursing Questions
1. The nurse is assessing a client's optic nerve (Cranial Nerve II). Which instruction should the nurse give the client to properly conduct this assessment?
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"Smile, raise your eyebrows, and puff out your cheeks."
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"Shrug your shoulders against my hands."
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"Stick out your tongue and move it from side to side."
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"Cover one eye and read the smallest line you can on the Snellen chart."
Explanation
Explanation
Correct Answer: (D) "Cover one eye and read the smallest line you can on the Snellen chart."
The optic nerve (Cranial Nerve II) is responsible for vision, and its function is properly assessed by testing visual acuity, which is accomplished by having the client cover one eye at a time and read progressively smaller lines on a Snellen chart.
Why the other options are incorrect:
A. "Smile, raise your eyebrows, and puff out your cheeks." — This instruction assesses Cranial Nerve VII (facial nerve) function, evaluating facial muscle movement, not vision.
B. "Shrug your shoulders against my hands." — This instruction assesses Cranial Nerve XI (spinal accessory nerve) function, evaluating trapezius muscle strength, not vision.
C. "Stick out your tongue and move it from side to side." — This instruction assesses Cranial Nerve XII (hypoglossal nerve) function, evaluating tongue movement, not vision.
Correct Answer: (D) "Cover one eye and read the smallest line you can on the Snellen chart."
The optic nerve (Cranial Nerve II) is responsible for vision, and its function is properly assessed by testing visual acuity, which is accomplished by having the client cover one eye at a time and read progressively smaller lines on a Snellen chart.
Why the other options are incorrect:
A. "Smile, raise your eyebrows, and puff out your cheeks." — This instruction assesses Cranial Nerve VII (facial nerve) function, evaluating facial muscle movement, not vision.
B. "Shrug your shoulders against my hands." — This instruction assesses Cranial Nerve XI (spinal accessory nerve) function, evaluating trapezius muscle strength, not vision.
C. "Stick out your tongue and move it from side to side." — This instruction assesses Cranial Nerve XII (hypoglossal nerve) function, evaluating tongue movement, not vision.
2. The nurse is reviewing the health history of a client during a routine exam. Which of the following findings are concerning risk factors for the development of coronary artery disease (CAD)? (Select all that apply)
Laboratory Reference Range: Total Cholesterol < 200 mg/dL
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The client lives a sedentary lifestyle with minimal physical activity
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The client has a total cholesterol level of 260 mg/dL
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The client's father had a myocardial infarction at age 48
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The client reports smoking one pack of cigarettes per day
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The client has a history of type 2 diabetes mellitus
Explanation
Explanation
Correct Answer: (A) Sedentary lifestyle, (B) Total cholesterol 260 mg/dL, (C) Father's MI at age 48, (D) Smoking one pack per day, (E) Type 2 diabetes mellitus — All options apply
All five findings are well-established, evidence-based risk factors for coronary artery disease. A sedentary lifestyle contributes to obesity and poor cardiovascular fitness. A cholesterol level of 260 mg/dL exceeds the normal reference range (<200 mg/dL), indicating hyperlipidemia. A father's myocardial infarction at age 48 represents a significant family history of premature CAD. Smoking damages blood vessel walls and accelerates atherosclerosis. Type 2 diabetes mellitus contributes to vascular damage and significantly increases cardiovascular risk.
Correct Answer: (A) Sedentary lifestyle, (B) Total cholesterol 260 mg/dL, (C) Father's MI at age 48, (D) Smoking one pack per day, (E) Type 2 diabetes mellitus — All options apply
All five findings are well-established, evidence-based risk factors for coronary artery disease. A sedentary lifestyle contributes to obesity and poor cardiovascular fitness. A cholesterol level of 260 mg/dL exceeds the normal reference range (<200 mg/dL), indicating hyperlipidemia. A father's myocardial infarction at age 48 represents a significant family history of premature CAD. Smoking damages blood vessel walls and accelerates atherosclerosis. Type 2 diabetes mellitus contributes to vascular damage and significantly increases cardiovascular risk.
3. The nurse is performing passive range of motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so that the toes are pointed toward the ceiling?
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Plantar flexion
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Eversion
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Inversion
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Dorsiflexion
Explanation
Explanation
Correct Answer: (D) Dorsiflexion
Dorsiflexion occurs when the ankle is bent so that the toes and foot move upward toward the shin/ceiling, decreasing the angle between the top of the foot and the anterior leg.
Why the other options are incorrect:
A. Plantar flexion — This motion involves pointing the toes downward, away from the shin (like pressing a gas pedal), which is the opposite movement of what is described.
B. Eversion — This motion involves turning the sole of the foot outward, away from the midline of the body, which is a different plane of movement than pointing the toes upward.
C. Inversion — This motion involves turning the sole of the foot inward, toward the midline of the body, which is also a different plane of movement than the vertical toe movement described.
Correct Answer: (D) Dorsiflexion
Dorsiflexion occurs when the ankle is bent so that the toes and foot move upward toward the shin/ceiling, decreasing the angle between the top of the foot and the anterior leg.
Why the other options are incorrect:
A. Plantar flexion — This motion involves pointing the toes downward, away from the shin (like pressing a gas pedal), which is the opposite movement of what is described.
B. Eversion — This motion involves turning the sole of the foot outward, away from the midline of the body, which is a different plane of movement than pointing the toes upward.
C. Inversion — This motion involves turning the sole of the foot inward, toward the midline of the body, which is also a different plane of movement than the vertical toe movement described.
4. A 72-year-old client reports feeling dizzy and nearly fainting while standing up. The client denies chest pain or shortness of breath. Which assessment should the nurse complete first?
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Auscultate the apical pulse for one full minute.
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Assess the client's orthostatic blood pressure and heart rate.
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Palpate for pitting edema in the lower extremities.
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Assess for jugular vein distention and peripheral pulses.
Explanation
Explanation
Correct Answer: (B) Assess the client's orthostatic blood pressure and heart rate.
The client's symptoms of dizziness and near-fainting upon standing are classic signs of orthostatic hypotension. Assessing orthostatic blood pressure and heart rate is the priority to identify significant drops in blood pressure associated with position changes, which directly relates to the reported symptoms.
Why the other options are incorrect:
A. Auscultate the apical pulse for one full minute. While assessing heart rate is important, it does not address the positional nature of the symptoms as specifically as orthostatic vital signs.
C. Palpate for pitting edema in the lower extremities. This assesses for fluid retention and is not the priority for symptoms related to dizziness upon standing.
D. Assess for jugular vein distention and peripheral pulses. This assessment is more relevant to cardiac and fluid volume status and is not the priority given the client's specific symptoms of orthostatic dizziness.
Correct Answer: (B) Assess the client's orthostatic blood pressure and heart rate.
The client's symptoms of dizziness and near-fainting upon standing are classic signs of orthostatic hypotension. Assessing orthostatic blood pressure and heart rate is the priority to identify significant drops in blood pressure associated with position changes, which directly relates to the reported symptoms.
Why the other options are incorrect:
A. Auscultate the apical pulse for one full minute. While assessing heart rate is important, it does not address the positional nature of the symptoms as specifically as orthostatic vital signs.
C. Palpate for pitting edema in the lower extremities. This assesses for fluid retention and is not the priority for symptoms related to dizziness upon standing.
D. Assess for jugular vein distention and peripheral pulses. This assessment is more relevant to cardiac and fluid volume status and is not the priority given the client's specific symptoms of orthostatic dizziness.
5. While assessing the client's cardiovascular system, the nurse auscultates a swishing sound. On documentation, the nurse describes a "harsh, blowing" sound. What is the nurse documenting?
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Normal heart sounds
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Referred lung sounds
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Murmur
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Gallop
Explanation
Explanation
A murmur is an extra or unusual sound heard during a heartbeat, often described as a swishing, harsh, or blowing sound. It results from turbulent blood flow through the heart valves or chambers.
Why the other options are incorrect:
A. Normal heart sounds Normal heart sounds are described as a crisp "lub-dub" (S1 and S2), not a swishing or blowing sound.
B. Referred lung sounds Lung sounds are respiratory in origin and are not what is being described when auscultating the cardiovascular system for this type of sound.
D. Gallop A gallop refers to extra heart sounds (S3 or S4) that create a rhythm similar to a horse's gallop, not a swishing or blowing sound.
A murmur is an extra or unusual sound heard during a heartbeat, often described as a swishing, harsh, or blowing sound. It results from turbulent blood flow through the heart valves or chambers.
Why the other options are incorrect:
A. Normal heart sounds Normal heart sounds are described as a crisp "lub-dub" (S1 and S2), not a swishing or blowing sound.
B. Referred lung sounds Lung sounds are respiratory in origin and are not what is being described when auscultating the cardiovascular system for this type of sound.
D. Gallop A gallop refers to extra heart sounds (S3 or S4) that create a rhythm similar to a horse's gallop, not a swishing or blowing sound.
6. The nurse is assessing a client and notes a scratch to their lower leg. When questioned about it, the client states their dog scratched the leg 3 months prior, "but it just seems slow to heal." The nurse notes there is no redness or heat, but the skin on the lower leg is hairless, has flaky skin, and is slightly darker than the upper extremities. Which condition should the nurse suspect?
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Lymphadenopathy
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Cellulitis
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Raynaud's Phenomenon
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Arterial insufficiency
Explanation
Explanation
Correct Answer: (D) Arterial insufficiency
The findings of hairlessness, flaky/dry skin, skin discoloration, and a slow-healing wound on the lower extremity are classic signs of arterial insufficiency, which results from reduced blood flow and oxygen delivery to the tissue, impairing the skin's normal nourishment, hair growth, and wound-healing capacity.
Why the other options are incorrect:
A. Lymphadenopathy — This refers to swollen or enlarged lymph nodes, which is unrelated to the skin changes and delayed wound healing described in this scenario.
B. Cellulitis — Cellulitis is a bacterial skin infection characterized by redness, warmth, swelling, and pain, none of which are present in this client's assessment findings.
C. Raynaud's Phenomenon — This condition involves episodic vasospasm typically affecting the fingers and toes in response to cold or stress, causing color changes, rather than the chronic skin and wound-healing changes described in this lower leg presentation.
Correct Answer: (D) Arterial insufficiency
The findings of hairlessness, flaky/dry skin, skin discoloration, and a slow-healing wound on the lower extremity are classic signs of arterial insufficiency, which results from reduced blood flow and oxygen delivery to the tissue, impairing the skin's normal nourishment, hair growth, and wound-healing capacity.
Why the other options are incorrect:
A. Lymphadenopathy — This refers to swollen or enlarged lymph nodes, which is unrelated to the skin changes and delayed wound healing described in this scenario.
B. Cellulitis — Cellulitis is a bacterial skin infection characterized by redness, warmth, swelling, and pain, none of which are present in this client's assessment findings.
C. Raynaud's Phenomenon — This condition involves episodic vasospasm typically affecting the fingers and toes in response to cold or stress, causing color changes, rather than the chronic skin and wound-healing changes described in this lower leg presentation.
7. The nurse is performing a peripheral vascular assessment on Henry Thompson, a 70-year-old client with a history of chronic kidney disease and peripheral artery disease. Based on the chart exhibit, which assessment finding requires immediate follow-up?
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Mild, non-pitting edema in bilateral lower extremities
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Absent dorsalis pedis pulse on the left foot
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Capillary refill 2 seconds
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Client reports occasional tingling in toes but denies pain
Explanation
Explanation
Correct Answer: (B) Absent dorsalis pedis pulse on the left foot
An absent dorsalis pedis pulse indicates a significant disruption in arterial blood flow to the foot, which is especially critical in a client with peripheral artery disease. This finding suggests possible severe arterial occlusion and places the client at risk for tissue ischemia and limb loss, requiring immediate follow-up.
Why Other Options are Incorrect:
A. Mild, non-pitting edema in bilateral lower extremities This is a mild finding that, while worth monitoring, does not indicate an acute vascular emergency requiring immediate action.
C. Capillary refill 2 seconds This is a normal finding, as capillary refill of less than 3 seconds indicates adequate peripheral perfusion.
D. Client reports occasional tingling in toes but denies pain Mild numbness without pain is a finding to monitor but is not as urgent as an absent pulse, which indicates a more acute compromise in blood flow.
Correct Answer: (B) Absent dorsalis pedis pulse on the left foot
An absent dorsalis pedis pulse indicates a significant disruption in arterial blood flow to the foot, which is especially critical in a client with peripheral artery disease. This finding suggests possible severe arterial occlusion and places the client at risk for tissue ischemia and limb loss, requiring immediate follow-up.
Why Other Options are Incorrect:
A. Mild, non-pitting edema in bilateral lower extremities This is a mild finding that, while worth monitoring, does not indicate an acute vascular emergency requiring immediate action.
C. Capillary refill 2 seconds This is a normal finding, as capillary refill of less than 3 seconds indicates adequate peripheral perfusion.
D. Client reports occasional tingling in toes but denies pain Mild numbness without pain is a finding to monitor but is not as urgent as an absent pulse, which indicates a more acute compromise in blood flow.
8. The nurse assesses a client's response to a noxious stimulus, as shown in the provided image. Which type of posturing is the client exhibiting?
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Decerebrate posturing
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Decorticate posturing
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Clonus
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Asterixis
Explanation
Explanation
Looking at the image, the client's arms are shown extended and rotated at the sides of the body, with legs extended, which is characteristic of decerebrate posturing. This abnormal posturing indicates a severe brainstem injury, as the extended limb position results from loss of inhibitory input to extensor muscle pathways.
Why the other options are incorrect:
B. Decorticate posturing — This posturing is characterized by flexion of the arms toward the core/chest with extension of the legs, which differs from the extended arm position shown in this image; decorticate posturing indicates a lesion above the brainstem (in the cerebral hemispheres or internal capsule).
C. Clonus — Clonus refers to rhythmic, involuntary muscle contractions typically seen at the ankle or wrist in response to reflex testing, not a static body positioning response to noxious stimuli.
D. Asterixis — Asterixis refers to a brief, involuntary "flapping" tremor of the hands (often seen in hepatic encephalopathy) elicited when the wrists are extended, not a full-body posturing response to painful stimuli.
Looking at the image, the client's arms are shown extended and rotated at the sides of the body, with legs extended, which is characteristic of decerebrate posturing. This abnormal posturing indicates a severe brainstem injury, as the extended limb position results from loss of inhibitory input to extensor muscle pathways.
Why the other options are incorrect:
B. Decorticate posturing — This posturing is characterized by flexion of the arms toward the core/chest with extension of the legs, which differs from the extended arm position shown in this image; decorticate posturing indicates a lesion above the brainstem (in the cerebral hemispheres or internal capsule).
C. Clonus — Clonus refers to rhythmic, involuntary muscle contractions typically seen at the ankle or wrist in response to reflex testing, not a static body positioning response to noxious stimuli.
D. Asterixis — Asterixis refers to a brief, involuntary "flapping" tremor of the hands (often seen in hepatic encephalopathy) elicited when the wrists are extended, not a full-body posturing response to painful stimuli.
9. A 67-year-old client arrives at the emergency department reporting sudden-onset weakness in their left arm and leg. The client is also having difficulty speaking clearly. Which assessment is most important for the nurse to complete?
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Perform a Romberg test to assess balance and coordination
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Check the client's grip strength and ability to stand without assistance
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Assess the client's ability to smile, raise both arms, and repeat a simple phrase
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Evaluate the client's deep tendon reflexes in the affected extremities
Explanation
Explanation
This client's presentation of sudden-onset unilateral weakness and slurred speech is highly suggestive of an acute stroke. The described assessment (facial symmetry, arm strength, and speech clarity) reflects the FAST (Face, Arms, Speech, Time) stroke assessment, which is the priority, rapid screening tool used to identify stroke symptoms and facilitate timely, potentially life-saving intervention.
Why the other options are incorrect:
A. Perform a Romberg test to assess balance and coordination — This test assesses proprioception and cerebellar function but is not the priority rapid assessment tool for suspected acute stroke, and may be unsafe to perform given the client's weakness.
B. Check the client's grip strength and ability to stand without assistance — While motor strength assessment is relevant, this is not the standardized, time-sensitive, priority screening approach (FAST) used for suspected stroke, and standing may pose a fall risk given the client's weakness.
D. Evaluate the client's deep tendon reflexes in the affected extremities — Reflex testing is not the priority rapid assessment for a client with suspected acute stroke symptoms; the FAST assessment takes priority to expedite time-sensitive stroke care.
This client's presentation of sudden-onset unilateral weakness and slurred speech is highly suggestive of an acute stroke. The described assessment (facial symmetry, arm strength, and speech clarity) reflects the FAST (Face, Arms, Speech, Time) stroke assessment, which is the priority, rapid screening tool used to identify stroke symptoms and facilitate timely, potentially life-saving intervention.
Why the other options are incorrect:
A. Perform a Romberg test to assess balance and coordination — This test assesses proprioception and cerebellar function but is not the priority rapid assessment tool for suspected acute stroke, and may be unsafe to perform given the client's weakness.
B. Check the client's grip strength and ability to stand without assistance — While motor strength assessment is relevant, this is not the standardized, time-sensitive, priority screening approach (FAST) used for suspected stroke, and standing may pose a fall risk given the client's weakness.
D. Evaluate the client's deep tendon reflexes in the affected extremities — Reflex testing is not the priority rapid assessment for a client with suspected acute stroke symptoms; the FAST assessment takes priority to expedite time-sensitive stroke care.
10. The nurse is performing a vascular assessment on a client with a history of hypertension and hyperlipidemia. While auscultating the carotid arteries, the nurse hears a low-pitched, turbulent sound over the left carotid artery. Which of the following findings should concern the nurse?
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The nurse notes the presence of a carotid bruit.
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The nurse notes a gentle, low-pitched sound over both carotid arteries.
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The nurse notes a regular rhythm of carotid pulsations.
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The nurse notes bilaterally symmetric carotid pulses.
Explanation
Explanation
A low-pitched, turbulent sound heard over the carotid artery is known as a bruit, which indicates turbulent blood flow often caused by arterial narrowing or atherosclerosis. This finding is especially concerning in a client with hypertension and hyperlipidemia, as it may signal significant vascular disease and increased risk for stroke.
Why the other options are incorrect:
B. The nurse notes a gentle, low-pitched sound over both carotid arteries. This does not describe an abnormal finding and does not match the turbulent sound described in the scenario.
C. The nurse notes a regular rhythm of carotid pulsations. A regular pulse rhythm is a normal finding and would not be a source of concern.
D. The nurse notes bilaterally symmetric carotid pulses. Symmetric pulses are a normal finding and would not indicate a problem requiring concern.
A low-pitched, turbulent sound heard over the carotid artery is known as a bruit, which indicates turbulent blood flow often caused by arterial narrowing or atherosclerosis. This finding is especially concerning in a client with hypertension and hyperlipidemia, as it may signal significant vascular disease and increased risk for stroke.
Why the other options are incorrect:
B. The nurse notes a gentle, low-pitched sound over both carotid arteries. This does not describe an abnormal finding and does not match the turbulent sound described in the scenario.
C. The nurse notes a regular rhythm of carotid pulsations. A regular pulse rhythm is a normal finding and would not be a source of concern.
D. The nurse notes bilaterally symmetric carotid pulses. Symmetric pulses are a normal finding and would not indicate a problem requiring concern.
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