ATI: Skills module 3.0- Comprehensive physical assessment of an adult Exam Questions and Answers

ATI: Skills module 3.0- Comprehensive physical assessment of an adult Exam Questions and Answers A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? - Ans ️️ -Kyphosis Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older clients who have had vertebral fractures. nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? - Ans ️️ -Balance The nurse should explain that the Romberg test is the most common test of balance. A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? - Ans ️️ -Inspection The first action the nurse should take using the nursing process is to assess the client. The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation. A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? - Ans ️️ -A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should be performed when you are preparing to auscultate the apical pulse. A nurse is performing a general client survey and finds that the client has a body mass index of 23. Which of the following should the nurse document? - Ans ️️ -The client has a BMI within the expected reference range. BMI is a measurement of an adult's body fat based on height and weight. The expected reference range for a BMI is between 18.5 and 24.9, which indicates a normal body weight. Therefore, the nurse should document that the client has a BMI within the expected reference range for a client who has a BMI of 23. A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the clients foot, between the tendons of the great toe and of those of the toe next to it, in order to palpate which of the following pulses? - Ans ️️ - Dorsalis pe