Health Assessment Ati Fundamentals Exam. Questions And Answers With Rationales.

70. A nurse is beginning a head to toe assessment for a client. In general, what order should the tasks be performed for each body system? A) Inspection, Palpation, Percussion, Auscultation B) Inspection, Percussion, Auscultation, Palpation C) Auscultation, Inspection, Palpation, Percussion D) Auscultation, Percussion, Palpation, Inspection 71. A nurse has been assigned to care for a client who has severe hearing loss. Which of the following actions would most positively contribute to therapeutic communication between nurse and client? SATA A) Help the client to speech-read by speaking face to face B) Speak clearly and in a normal tone of voice C) Overemphasize facial expressions D) Refrain from using pictures to clarify understanding E) Avoid discussing the client's level of hearing loss 72. A 29-year-old pregnant client arrives at the hospital in active labor. The client is deaf and her husband is with her. Which intervention from the nurse expresses her ability to communicate with this client? A) Assess the communication ability of the client and her husband and ask them what they would prefer B) Use exaggerated lip movements to allow the client to read lips C) Mime what needs to be done in order to communicate D) Arrange for a sign language interpreter who can be present during the delivery 73. A nurse is caring for a postpartum client who is Vietnamese and speaks little English. Because of complications with delivery, the mother experienced a larger amount of blood loss, and the provider has ordered an increase in IV fluids as well as encouraging oral intake of fluids. The nurse brings the mother a pitcher of ice water and the client becomes visibly upset. Which response from the nurse is most appropriate? A) Would you feel better having something different to drink? B) You need to drink water so you will not become dehydrated C) Is there something wrong that you do not like water? D) Are you having any pain? 74. The nurse is caring for a client who does not speak English, but has a son in the room who speaks English. The nurse learns the client will be going to surgery for a below-the-knee amputation shortly, and the surgeon is on the way to speak with the client. Which of the following is the nurse's priority? A) Calling for an interpreter to get informed consent for surgery signed B) Starting a second IV for additional access intra-procedure C) Making sure an H&P is on the chart D) Assessing pedal pulses q2hrs 75. A nurse is caring for a client who is visually impaired. What action by the nurse will decrease anxiety in this client? A) Alerting the client when approaching B) Speaking in a lower voice to the client C) Walking behind the client when ambulating D)Assisting the client as much as possible 76. A triage nurse in the emergency room is assessing a client who has come in to the hospital under the influence of alcohol and cocaine. The client is screaming and crying at the nurse and telling her that she wants to leave. Which action of the nurse would be best during initial de-escalation of this client? A) Maintaining a calm demeanor and facial expression B) Asking the client what is wrong and what she really wants C) Keeping the door open and the lights on in the room D) Advising the client that her behavior is out of control and she needs to calm down 77. When caring for a client who is hearing-impaired, the priority nursing action is which of the following? A) Be positioned directly in front of the client B) Keep the lights dim C) Talk in a high voice D) Move closer to the affected ear 78. A client has been brought to the pre-op area to have his IV started before undergoing hernia surgery. The client is extremely anxious and starts crying when the nurse walks into the room. Which intervention would be most appropriate in this situation to help with the client's anxiety? A) Ask the client if there is anyone that came with him that he wants nearby B) Ask the client to calm down so the nurse can talk to him C) Contact the provider for prescription sedative agents D) Give the client some sips of water 79. A diabetic client in the care clinic is complaining of feeling anxious. The nurse notes that the client is sweaty, has tremors, and is tachycardic. Which intervention would the nurse most likely perform in response? A) Check the client's blood glucose B) Connect the client to a hemodynamic monitor C) Give the client a drink of water D) Assist the client to lie down 80. A nurse is caring for a client who needs an MRI for a back injury. The client is deaf. The nurse has provided written information for the client but needs to find out if there are any questions. In which way would the nurse most likely act as the client's advocate? A) Call an interpreter to talk to the client B) Mime the actions the client needs to know C) Use a video with closed-captioning that will explain the procedure D) Call the radiology department and ask them to explain the procedure