NURS 310 ATI questions

A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with the client? (Select all that apply)

Use a mix of open-ended and close-ended questions

Reduce environmental noise

Perform the general survey before examination

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the follow interventions should the nurse use in consideration of the client’s age? (Select all that apply)

Plan to allow plenty of time for position changes

Make sure the client has any essential sensory aids in place

Tell the client to take their time answering questions

Invite the client to use the bathroom before beginning examination

A nurse in a provider’s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpating for optimal assessment of skin temperature?

Dorsal surface

A nurse is obtaining a health history of a client’s comprehensive physical examination. After inspecting the clients abdomen, which of the following skills of the physical examination process should the nurse perform next?

Auscultation

A nurse in a provider’s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply)

Posture

Skin lesions

Speech

Definition of back channeling

Use active listening phrases (“Go on” and “tell me more”) to convey interest and prompt disclosure of the entire story

Definition of clarifying

Question clients about specific details in greater depth or direct them toward relevant parts of their history

Definition of open-ended questions

Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand

Definition of active listening

Show clients that they have your undivided attention

Definition of summarizing

Validate the accuracy of the story

Definition of probing

Ask more open-ended questions (“what else would you like to add to that?”) to help obtain comprehensive information

Definition of close-ended questions

Ask questions that require yes or no answers to clarify information (“do you have any pain when you cannot sleep?”)

If a client breathes through the mouth, where should the nurse take their temp?

Rectal temp route

If a client who has a low platelet count, where should the nurse take their temp?

Oral temp route

If a client has facial trauma, where should the nurse take their temp?

Rectal temp route

If a client has hemorrhoids, where should the nurse take their temp?

Oral temp route

A nurse is caring for a client who has an oral temp of 38.6 C, heart rate 114/min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (Select all that apply.)

Obtain cultural specimens before initiating antimicrobials

Encourage the client to rest and limit activity

Assist the client with oral hygiene frequently

A nurse determines a client’s radial pulse is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit?

14/min

A nurse is instructing an ẬP how to measure a client’s respiratory rate. Which of the following statements should the nurse include? (Select all that apply.)

Place the client in Semi-Fowler’s position

Have the client rest an arm across the abdomen

Observe one full respiratory cycle before counting the rate

A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first?

Ask the client if they are having pain.

A nurse is assessing a client’s thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)

Palpating the thyroid in the lower half of the neck

Visualizing the thyroid on inspection of the neck

Finding symmetric extension of the trachea on both sides of the midline

Which CNs are both sensory and motor?

the trigeminal (CN V), facial (CN VII), glossopharyngeal (CN IX), and vagus (CN X).

Where is the submental lymph node located?

Under the chin

Where are the postauricular lymph nodes located?

Over the mastoid

Where are the anterior cervical lymph nodes located?

Along the sternocleidomastoid muscle

Where are the tonsils nodes located?

Angle of the mandible

Where are the occipital nodes located?

Base of the skull

A nurse is preparing to inspect the ears, nose, mouth, and throat of a client. Which of the following equipment does the nurse need?

Tongue blade

Penlight

Gauze square

What technique should the nurse use when conducting a Rinne test (air conduction)?

The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard.

What technique would the nurse use when conducting a Weber test (bone conductivity)?

The nurse places a vibrating tuning fork on the top of the head and asks the client if the sound is best heard in the left or right ear.

What technique would the nurse use when conducting a whisper test?

The nurse stands behind the client, covering one ear, and whispers a word or phrase, asking the client to repeat it.

If patient hears a sound in affected ear during Weber test, what does this mean?

It indicates conductive hearing loss in that ear, as sound lateralizes to the poorer hearing ear.

If patient hears a sound in unaffected ear during Weber test, what does this mean?

It indicates sensorineural hearing loss in the affected ear, as sound lateralizes to the better hearing ear.

If patient hears a vibration in air > bone during Rinne test, what does this mean?

Normal hearing or sensorineural hearing loss

If patient hears a vibration in bone > air during Rinne test, what does this mean?

Conductive hearing loss

The tonsils touch the uvula.

This indicates a grade 3 tonsil enlargement, where the tonsils are significantly enlarged and may obstruct the airway.

The tonsils are behind the soft structures supporting the palate

Grade 1

The tonsils touch each other

Grade 4

The tonsils are between the soft structures and uvula

Grade 2 enlargement, where the tonsils are enlarged but do not reach the uvula.

A nurse in a provider’s office is preparing to test a client’s CN function. Which of the following actions should the nurse take? (Select all that apply.)

“Clench your teeth”

“Tell me when you feel a touch”

A nurse is assessing an adult client’s internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.)

“Insert the speculum slightly down and forward

“Make sure the speculum does not touch the ear canal

“Use the light to visualize the tympanic membrane in a cone shape

A nurse is caring for a client who asks wha their Snellen eye test results mean. The client’s visual acuity 20/30. Which of the following responses should the nurse make?

“Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect?

Tooth loss

Glare intolerance

Thickened eardrums

A nurses is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply.)

The client’s nipples are everted

The client’s left breast is smaller than the right breast

The client’s areolae are oval shaped

The underlying veins in the breast are visible

Where is the midaxillary line?

Runs down from the apex of axillary

Where is the anterior axillary line

Extends down from the anterior axillary fold

Where is the midsternal line

Over the center of the sternum

Where is the vertebral line

Alone the center of the spine

A nurse is auscultating a client’s lungs. Which of the following findings are expected? (Select all that apply.)

Expiration is longer than inspiration over the trachea upon auscultation

Soft, breezy, low-pitched sounds

A nurse in a provider’s office is preparing to auscultation and percuss a client’s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)

Tympani

High-pitched clicks

A nurse in a provider’s office is preparing to auscultation and percuss a client’s throat as part of a comprehensive physical exam. Which of the following findings should the nurse expect (select all that apply.)

Resonance

Bronchovesicular sounds

During an abdominal examination, a nurse in a provider’s office determines that a client has an abdominal distinction. The protrusion is at midline, the skin is over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distinction should the nurse suspect?

Flatus (protrusion mainly midline)

During a cardiovascular exam, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.)

Closure of the mitral valve

Apical heart rate

Closure of the mitral valve

Examples of macule?

Freckle, petechiae

Examples of papule?

Elevated nevus

Examples of nodule?

Wart

Examples of vesicle?

Blister, herpes simplex, varicella

Examples of pustule?

Acne

Examples of tumor?

Epithelioma

Examples of wheal?

Insect bite

What is the assessment of lesions?

A: asymmetry of shape

B: border irregularity

C: color variation within one lesion

D: diameter greater than 6 mm

E: evolving/change in color, elevation shape, size or development in itching, crusting, bleeding

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings is the nurse’s priority?

Cyanosis

A nurse is performing a peripheral vascular assessment of the lower extremities on a client who is postoperative following knee surgery. What information should the nurse include in the assessment?

Check and compare skin color and temperature of client’s lower extremities.

A nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply).

Capillary refill < 3 seconds

Thick skin on soles of the feet

2+ pulses on client’s lower extremities

A nurse is performing a skin assessment on an older adult client. Which are expected and unexpected findings among older adult clients?

Thin, parchment-like skin

Hematoma

Diminished skin elasticity

Wrinkles

Petechiae

Unexpected: Hematoma, Petechiae

Expected: Diminished skin elasticity, thin parchment-like skin, wrinkles

Which CN is associated with sticking out the tongue?

XII Hypoglossal CN

Which CN is associated with checking speech for hoarseness?

X Vagus CN

Which CN is associated with identifying a sour taste at the back of the tongue?

IX Glossopharyngeal CN

Which CN is associated with shrugging the shoulders?

XI Spinal Accessory CN

The client is experiencing difficulty swallowing. Which of the following CN controls swallowing?

IX Glossopharyngeal CN

A nurse is assessing a client’s musculoskeletal system as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (select all that apply)

Concave lumbar spine posteriorly

Muscles slightly larger on the dominant side

A nurse is performing a neurologic exam for a client. Which of the following assessments should the nurse perform to test the client’s balance?

Romberg test, which assesses the client's ability to maintain balance while standing with their feet together and eyes closed.

A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client?

Encourage the client to communicate their thoughts and feelings.

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (select all that apply)

Use an open posture

Establish and maintain eye contact

Sit facing the client

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

Sit at eye level with the child.

Which are effective and ineffective techniques/skills?

Ineffective: Stereotyping, Challenging, Approving, Asking for an explanation

Effective: Clarifying, Active Listening

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (select all that apply)

“Your daily routines will be different when you get home”

“Tell me about the support system you’ll have after you leave the hospital”

“It sounds like you are not sure how having a colostomy will affect swimming”

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize the response as which part of the general adaptation syndrome (GAS)?

Alarm stage

A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, “How could you possibly understand what I am going through?” Which of the following responses should the nurse make?

“You are right. I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling.”

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (select all that apply)

Allow the client to provide input in the treatment plan

Assist the client with time management, and address the client’s priorities

Encourage the client in the expression of feelings and concerns

A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?

Convening to a family meeting

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concepts?

“I’ll never be able to care for this at home. Can’t you just send a nurse to the house?”

A nurse is caring for a group of clients on a med surg unit. Which of the following clients are at increased risk for body-image disturbances. (select all that apply)

Client who had mastectomy (breast removal)

Client who had left above-the-knee amputation

Client who had a stroke with ride-sided hemiplegia

A nurse is caring for a client who is 3 days post-op following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image?

“I don’t even want to look at my leg. You can check the dressing.”

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, “I am concerned that things might be a little ‘different’ with my partner when I get home.” Which of the following statements should the nurse make?

“It's natural to have concerns about intimacy after a medical event; let's talk about what you're feeling."

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client’s role problem?

Role conflict

A nurse is caring for a client who is expected to die within 24 hr. The client’s family asks the nurse what physical changes to expect. Which manifestations should the nurse include? (select all that apply)

Decreased muscle tone

Periods of apnea

Bowel incontinence

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting the client with all ADLs. What rationale for self-care should the nurse communicate to the family?

The nurse should communicate with client’s family that they should allow the client to independently perform ADLs.

A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take? (select all that apply)

Place a clean gown on the client’s body

Remove all equipment from the client’s bedside

Dim the lights in the client’s room

A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include?

Dry mouth is common for older adults.

A nurse is providing a client with a complete bed bath? Which is the correct order to bathe the body?

Face, trunk, legs, feet

A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (select all that apply)

Wash the feet daily, using warm water

Smooth the edges of the toenails with an emery board

A nurse is performing mouth care for an unconscious client. Which of the following actions should the nurse take?

Turn the client’s head to the side to prevent aspiration.

A nurse is providing a denture care for a client. Which of the following actions should the nurse take?

Using a gauze pad to grasp and pull forward and downward to remove the upper denture

What are the factors of Stage 1 NREM?

Very light sleep; few minutes long; muscle relaxation; decrease in vital signs and metabolism; easily awakened; relaxed and drowsy

What are the factors of Stage 2 NREM?

Deeper sleep; 10-20 min long; requires more stimulation to awaken; vital signs and metabolism continues to slow

What are the factors of Stage 3 NREM?

Slow wave/delta sleep; decreased vital signs; reduced sympathetic activity

What are the factors of REM?

Vivid dreaming; about 90 min after falling asleep; longer with each cycle; avg length of 20 min; very difficult to awaken; loss of skeletal m. tone

A nurse is preparing a presentation at a local community center about sleep hygiene. Which are NREM characteristics

Light sleep; 75% of time sleeping

A nurse is preparing a presentation at a local community center about sleep hygiene. Which are REM characteristics

Cognitive restoration occurs; Loss of muscle tone occurs; Vivid dreaming occurs