ATI RN
ATI Fundamentals Assessment Exam Midterm Questions
Extract:
Question 1 of 5
When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?
Correct Answer: B
Rationale: The correct answer is B: Limit position changes as much as possible. In a client with generalized muscle weakness, limiting position changes is crucial to prevent fatigue and further muscle weakness. Moving the client too frequently can exacerbate their already compromised muscle strength. Draping (choice
A) and hand-washing (choice
C) are important but not the priority in this situation. Using alcohol swabs to clean the stethoscope (choice
D) is also not a priority compared to the need to minimize position changes to prevent muscle fatigue.
Question 2 of 5
A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say 'ee,' and if the sound is heard as 'ay,' this is known as:
Correct Answer: D
Rationale:
Rationale: The correct answer is D, Egophony. Egophony occurs when the patient is asked to say 'ee,' but the sound heard is distorted and sounds like 'ay.' This phenomenon indicates consolidation of the lung tissue, common in conditions like pneumonia.
Summary of other choices:
A) Bronchovesicular sound is a type of breath sound, not related to voice resonance.
B) Bronchophony refers to increased transmission of voice sounds, not distortion.
C) Normal voice resonance would produce clear 'ee' sounds.
Question 3 of 5
While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?
Correct Answer: B
Rationale: The correct answer is B: The need for regular mammogram screening to identify breast cancer lesions. This is the most likely information the nurse provided for secondary prevention. Mammogram screening helps detect breast cancer early, improving treatment outcomes.
Choice A is more related to primary prevention through immunizations.
Choice C is important for injury prevention but not specific to health assessment.
Choice D is focused on vision examinations, which are important but not typically part of secondary prevention activities.
Question 4 of 5
A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?
Correct Answer: B
Rationale: The correct answer is B: Sclera of the eye. The sclera is the white part of the eye, and jaundice is often first noticeable in this area due to the yellow discoloration caused by elevated levels of bilirubin in the blood. In this case, with the patient having liver cirrhosis and jaundice, the sclera would be the most reliable area to inspect. The conjunctiva (choice
A) can also show jaundice, but it may be less noticeable compared to the sclera. The back of the neck (choice
C) and palms of the hands (choice
D) are not typically reliable areas to assess for jaundice.
Question 5 of 5
The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?
Correct Answer: A
Rationale: The correct approach is A. By beginning above the right clavicle and percussing each section, comparing the right chest with the left chest, the nurse ensures a systematic and comprehensive assessment. This method allows for a structured evaluation of symmetry, resonance, and any abnormal findings. Starting above the right clavicle helps to maintain consistency and uniformity in the assessment process. It also enables the nurse to easily compare corresponding areas on both sides, aiding in the identification of any differences or abnormalities. This approach follows the standard practice of chest percussion and promotes thorough data collection for accurate interpretation.
Summary of other choices:
B: This approach does not involve comparing the right and left chest simultaneously, potentially missing important differences between the two sides.
C: Percussing all areas on one side before the other may lead to overlooking differences between the sides, reducing the effectiveness of the assessment.
D: Beginning above the left clavicle and moving upward from the liver is not a standard approach for chest percussion and may