ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 5 : Adult Health and Nutritional Assessment Questions
Question 1 of 5
The nurse is performing the process of inspection during an assessment. What nursing action should the nurse include during this phase?
Correct Answer: B
Rationale: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. It is specific information, not general information, that is being gathered. Writing while observing can be a conflict for the nurse. It is not necessary or appropriate to keep the assessment concealed from the patient.
Question 2 of 5
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?
Correct Answer: C
Rationale: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.
Question 3 of 5
During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle component of percussion?
Correct Answer: D
Rationale: The principle of percussion is to set the vibration in the chest wall or abdominal wall into vibration by striking it with a firm object. Percussion is not limited to dead spaces or the abdomen. The body does not create the sounds resulting from percussion; sound is referred from striking the surface of the body.
Question 4 of 5
A nurse practitioner's assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which Anya of the following is the nurse able to assess?
Correct Answer: A
Rationale: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver, and the presence of rectal distention cannot be assessed by percussion.
Question 5 of 5
A 51-year-old woman's recent complaints about fatigue are thought to be attributable to iron deficiency anemia. The patient's subsequent diagnostic testing includes quantification of her transferrin blood levels. This biochemical assessment would be performed by assessing which of the blood following?
Correct Answer: B
Rationale: Biochemical assessments are made from studies of serum (albumin, transferrin, ferritin, retinol, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). Transferrin is found in serum, not urine, CSF, or synovial fluid.