Video Library
Ati health assessment exam 2
Ati health assessment exam 2
Total Questions : 36
Showing 10 questions Sign up for moreWhen assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.
Explanation
A. A lesion that is asymmetrical is concerning, as melanoma and other skin cancers tend to be irregular in shape. This is an important warning sign.
B. Red and black coloration in a lesion is concerning because it can indicate changes in blood flow or necrosis, both of which are suspicious for malignancy.
C. A flat lesion does not automatically indicate a problem, as many benign lesions, like moles, can be flat. The texture or elevation of the lesion is not always a concern unless there are other risk factors.
D. A lesion larger than 6 mm is concerning, especially if it is changing in size or shape. Larger lesions should be evaluated by a healthcare provider for potential malignancy.
E. Round edges are typically a characteristic of benign lesions, so this is not as concerning unless there are other warning signs present.
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Explanation
A. Cranial nerve V (trigeminal) is not directly related to ataxia or balance. It is more involved in sensory perception of the face and motor function for chewing.
B. Kernig's sign is a test for meningitis, not ataxia or balance issues. It involves flexing the hips and knees to check for resistance or pain that may suggest meningeal irritation.
C. Clubbing is related to chronic oxygenation issues or respiratory/cardiovascular conditions, but it is not a direct assessment of ataxia or balance.
D. A Romberg's test is used to assess balance and proprioception. By having the client stand with feet together and eyes closed, the nurse can assess the client's ability to maintain balance and identify any unsteadiness or ataxia that may impair safe ambulation.
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
Explanation
A. The nurse is legally obligated to report suspected child abuse according to mandatory reporting laws. This response directly addresses the nurse’s legal responsibility without providing unnecessary details to the parents.
B. Reporting the incident to a supervisor does not fully address the nurse's legal obligation, which is to report the abuse to the authorities.
C. It is inappropriate to defer to the provider in this case, as the nurse holds the legal responsibility to report the suspicion.
D. The nurse should not avoid the discussion but instead provide a clear, legal explanation for their actions.
When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.
Explanation
A. The groin area is prone to skin breakdown due to friction, moisture, and pressure, especially in immobile patients.
B. The coccyx (tailbone) is a high-risk area for pressure ulcers due to constant pressure when sitting, particularly in bedridden patients.
C. The heels are vulnerable to pressure ulcers because they are under constant pressure when lying down or when standing for prolonged periods.
D. While the scapula may be at risk in certain conditions (e.g., if the patient is immobile and lying on their back), it is generally not as high-risk as other areas like the coccyx or heels.
E. This area is at risk due to moisture, friction, and pressure from the breast tissue, especially in obese or immobile patients.
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Explanation
A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.
C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)
Explanation
A. A family history of skin cancer can increase the risk of developing the condition.
B. While individuals with dark skin have a lower risk of developing skin cancer, they are not immune to it, and this option is not as strong a risk factor as others.
C. Prior skin injuries, such as burns or scars, can increase the likelihood of skin cancer developing in those areas.
D. Skin cancer risk generally increases with age, making this not a strong risk factor.
E. UV light is a major risk factor for developing skin cancer due to its damage to skin cells and DNA.
When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?
Explanation
A. Confluent lesions merge together, forming a larger area of affected skin, which is not the case here.
B. Discrete lesions are separate and distinct from each other, which doesn't match the description of clusters.
C. Grouped lesions are those that appear in clusters, which fits the assessment finding.
D. Annular lesions have a ring-like appearance, typically seen in conditions like ringworm, and do not fit the description of clustered lesions.
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Explanation
A. While an eye patch may be needed for other conditions (e.g., facial paralysis), it is not a primary concern in this case.
B. Range-of-motion exercises are not related to cranial nerve IX and X impairment.
C. Avoiding warm water to wash the face is not specifically relevant to cranial nerve impairment.
D. Suction equipment should be available for clients with cranial nerve impairment, especially if they have swallowing difficulties or potential for aspiration.
What is stereognosis?
Explanation
A. This refers to the ability to hear words whispered in the whisper test, which assesses hearing, not stereognosis.
B. Stereognosis is the ability to identify objects through touch alone, with the eyes closed.
C. This refers to graphesthesia, the ability to recognize writing on the skin, not stereognosis.
D. This refers to the Rinne and Weber tests, which assess hearing function, not tactile sensation.
A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?
Explanation
A. Increased intraocular pressure causes glaucoma, not diabetic retinopathy.
B. Clouding of the lens is related to cataracts, not diabetic retinopathy.
C. Seeing spots or floaters is a common symptom of diabetic retinopathy.
D. Diabetic retinopathy requires more frequent eye exams (typically annually) for early detection.
You just viewed 10 questions out of the 36 questions on the Ati health assessment exam 2 Exam. Subscribe to our Premium Package to obtain access on all the questions and have unlimited access on all Exams. Subscribe Now
