Health Assessment ATI EXAM 2020

Search Create Upgrade to Quizlet Plus jeszoequiz 30 terms Vanessa_Gonzalez49 Health Assessment ATI EXAM 1 STUDY LEARN FLASHCARDS WRITE SPELL TEST PLAY MATCH GRAVITY Upgrade to remove ads Only $1/month SORT A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply) A. Address the client with the appropriate title and her last name. B. Use a mix of open- and close-ended questions. C. Reduce environmental noise. D. Have the client complete a health history form. E. Perform the general survey before the examination. B, C, E Rationale: B. Open-ended questions help the client tell her story in her own way. Closed-ended questions are useful for clarifying and verifying information the nurse gathers from the client's story C. quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. E. The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process, such as the examination A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies. E. immunization status A, B, C Rationale: A. Posture is part of the body structure or general appearance portion of the general survey. B. Skin lesions are part of the body structure or general appearance portion of the general survey. C. Speech is part of the behavior portion of the general survey A nurse is collecting data for a client's comprehensive physical examination. after the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A.olfaction B.auscultation C.Palpation D.Percussion B Rationale: B. Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) a.Collect the data in one continuous session. B.Plan to allow plenty of time for position changes. C.Make sure the client has any essential sensory aids in place. D. tell the client to take her time answering questions. E. invite the client to use the bathroom before beginning the examination B, C, D, E Rationale: B. Because many older adults have mobility challenges, the nurse should plan to allow extra time for position changes. C. the nurse should make sure clients who use sensory aids have them available for use. the client has to be able to hear the nurse and see well enough to avoid injury. D. Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication. E. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity. A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A.Palmar surface B.Fingertips C.Dorsal surface D.Base of the fingers C Rationale: C. The dorsal surface of the hand is the most sensitive to temperature. A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) A.Obtain culture specimens before initiating antimicrobials. B.Restrict the client's oral fluid intake. C.Encourage the client to rest and limit activity. D. allow the client to shiver to dispel excess heat. E. assist the client with oral hygiene frequently A, C, E Rationale: A. he provider can prescribe cultures to identify any infectious organisms causing the fever. the nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. C.Rest helps conserve energy and decreases metabolic rate. activity can increase heat production E. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips A nurse is instructing an assistive personnel (aP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A."Do not measure the client's temperature rectally." B."Count the client's radial pulse for 30 seconds and multiply it by 2." C."Do not let the client know you are counting her respirations." D."let the client rest for 5 minutes before you measure her blood pressure." A Rationale: A. The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. the low platelet count contraindicates the use of the rectal route for this client. A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A.Place the client in semi-Fowler's position. B.Have the client rest an arm across the abdomen. C.Observe one full respiratory cycle before counting the rate. D.Count the rate for 30 sec if it is irregular. E.Count and report any sighs the client demonstrates. A, B, C Rationale: A. Having the client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements. B. With the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements. C. Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count. D. the students should count the rate for 1 min if it is irregular A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. the client denies any history of hypertension. Which of the following actions should the nurse take first? A.Request a prescription for an antihypertensive medication. B. ask the client if she is having pain. C.Request a prescription for an anti-anxiety medication. D.Return in 30 min to recheck the client's blood pressure B Rationale: