Ati physical assessment quiz

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Question 1: View When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

A. Flat B. Protuberant C. Rounded D. Scaphoid

Explanation

A. Flat: A flat abdomen is level with no visible protrusions or concavities.

B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.

C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.

D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.

Question 2: View The nurse receives the primary provider's order of phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer. (Round to the nearest whole number)

A. 20 B. 0.2 C. 2 D. 200

Explanation

A. 20: Incorrect, as it would imply a much higher dose.

B. 0.2: Incorrect, as this would be far too low.

C. 2: Phenytoin 0.2 g is equivalent to 200 mg (0.2 g x 1000 mg/g). Since each capsule is 100 mg, the nurse would need to administer 2 capsules (200 mg / 100 mg per capsule = 2).

D. 200: Incorrect, as 200 capsules would be an overdose.

Question 3: View A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

A. Positive skin hypersensitivity test. B. Positive Rovsing sign. C. Psoas sign. D. Positive Obturator sign.

Explanation

A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.

B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.

C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.

D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.

Question 4: View The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?

A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. B. The client who does not have a palpable thrill or auscultated bruit. C. The client who is reporting a 3.6 kg weight gain and it refusing dialysis. D. The client who has a hemoglobin of 9.0 mg/dL (12.0-15.5 mg/dL) and hematocrit of 26% (36.1% -44.3%).

Explanation

A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.

B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.

C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.

D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.

Question 5: View A client's bladder is found to be distended. At which location would the nurse begin palpating?

A. At the symphysis pubis. B. In the left lower quadrant. C. At the umbilicus. D. In the right lower quadrant.

Explanation

A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.

B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.

C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.

D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.

Question 6: View

The nurse is caring for a 33-year-old male client who has visited the primary healthcare provider for several months stating that he is experiencing "heartburn" after lunch and dinner. He reports that these episodes last about an hour after eating, and are much worse if he lays down to sleep after a meal. Most of the time, he also experiences belching and bloating with "heartburn" that feels like chest pain. He has been taking over-the-counter antacids with minimal relief. He says that his wife sent him today because she was getting concerned about the number of antacids he has been using. Reading the electronic health record, the nurse notes:

id="exhibits">Exhibits

What subjective assessment information in this client situation is the most important and immediate concern for the nurse?

A. Belching B. chest pain C. Flatulence D. Pain with position

Explanation

A. Belching: Belching is a common symptom associated with GERD or indigestion, but it is not as critical as chest pain.

B. Chest pain: Chest pain is the priority because it can sometimes be a sign of serious conditions, such as gastroesophageal reflux disease (GERD) mimicking angina, or even cardiac issues. This must be ruled out before considering other symptoms.

C. Flatulence: This is also a typical symptom with digestive issues but does not present an immediate concern compared to chest pain.

D. Pain with position: Although positional pain is common with GERD, it does not warrant immediate concern like chest pain, which could indicate a potential cardiac issue.

Question 7: View Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?

A. Abdominal x-ray B. Shifting dullness C. Fluid wave D. Ultrasound

Explanation

A. Abdominal x-ray: While it can show gas or bowel obstructions, it is less effective for confirming fluid presence.

B. Shifting dullness: This physical exam technique can indicate fluid but is less accurate than ultrasound.

C. Fluid wave: This physical exam can help suggest the presence of fluid, but it is also less reliable than imaging studies.

D. Ultrasound: An ultrasound is the most accurate and non-invasive way to confirm the presence of fluid, such as ascites, in the abdomen. It provides detailed imaging and confirmation without invasive procedures.

Question 8: View A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

A. Intake and output B. Daily weight C. Sodium level D. Skin tenting

Explanation

A. Intake and output: Although helpful, intake and output measurements can sometimes be inaccurate, as not all fluid retention may be recorded.

B. Daily weight: Daily weight measurements are the most reliable way to assess fluid retention because changes in body weight accurately reflect gains or losses in body fluid, especially in clients with chronic kidney disease.

C. Sodium level: Sodium levels can indicate fluid imbalances, but they do not directly measure fluid volume excess.

D. Skin tenting: Skin tenting is used to assess dehydration, not fluid retention, and is not a reliable measure in chronic kidney disease.

Question 9: View The client is brought into the emergency room (ER) by paramedics with blunt trauma to the left upper side of the abdomen due to a motor vehicle accident. The ER nurse knows what organ is most likely impacted.

A. appendix B. left ureter C. left lobe of liver D. sigmoid colon

Explanation

A. Appendix: Located in the right lower quadrant, the appendix is unlikely to be impacted in left upper quadrant trauma.

B. Left ureter: The left ureter is located lower in the abdomen along the flank area and is not directly impacted in the left upper quadrant.

C. Left lobe of liver: The liver’s left lobe extends into the left upper quadrant, making it a likely organ to be impacted in blunt trauma to this area, particularly given its large size and location near the abdominal wall.

D. Sigmoid colon: Positioned lower in the left lower quadrant, the sigmoid colon is less likely to be affected by left upper abdominal trauma.

Question 10: View A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

A. Postural hypotension B. Dependent edema C. Bradycardia D. Distended neck veins

Explanation

A. Postural hypotension: Postural hypotension (a drop-in blood pressure when moving to a standing position) is a common sign of extracellular fluid volume deficit due to decreased circulating blood volume.

B. Dependent edema: This occurs with fluid volume excess, not deficit, due to fluid accumulation in tissues.

C. Bradycardia: Fluid volume deficit often leads to tachycardia as the body compensates for low blood volume, rather than a slow heart rate.

D. Distended neck veins: Distended neck veins suggest fluid overload, not a fluid deficit.

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