ATI LPN
Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 21 : Physical Assessment Questions
Question 1 of 5
Explain the importance of performing an initial shift assessment within the first hour of your shift.
Correct Answer: D
Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.
Question 2 of 5
What assessments should you make of the lower extremities in an initial shift assessment?
Correct Answer: D
Rationale: Lower extremity assessment includes pulse strength, edema, skin condition, range of motion, capillary refill, temperature, sensation, strength, color, and mobility.
Question 3 of 5
Describe the assessments that should be performed in relation to these limited data.
Correct Answer: D
Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.
Question 4 of 5
Describe the assessments that you will perform to establish the status of his renal system and ensure that he is not getting into fluid overload problems.
Correct Answer: D
Rationale: Renal system assessment includes urine output, weight, edema, breath sounds, blood pressure, serum creatinine, BUN, fluid intake, and electrolyte levels to monitor for fluid overload.
Question 5 of 5
Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).