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ATI Health Assessment Exam
Total Questions : 35
Showing 10 questions, Sign in for moreSkin Assessment
Highlight the abnormal findings that the nurse should be concerned about. Select all that apply.
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.
Explanation
A change in the size of a mole is a significant red flag and should be concerning for potential skin cancer, particularly melanoma. A mole that enlarges over time, especially if it changes size rapidly, can indicate the development of malignant melanoma.
Color changes in a mole, such as darkening, lightening, or developing multiple colors, should raise concern for melanoma. Melanomas often present with uneven pigmentation, where the mole may become more than one color, such as black, blue, red, or brown. This change in color is abnormal and requires further investigation.
Itching and burning are abnormal symptoms associated with skin lesions and can be indicative of skin cancer. These sensations can occur when the skin becomes irritated or inflamed due to a growing malignancy such as melanoma.
Bleeding from a mole is a red flag and is concerning for skin cancer, especially melanoma. A mole that bleeds or oozes may be ulcerating or eroding, which are signs of more advanced skin cancer.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
A heart murmur should be assessed for which of the following? Select all that apply.
1200:
- Temperature 38.6° C (101.5° F)
- Heart rate 109/min
- Respiratory rate 28/min
- Blood pressure 106/54 mm Hg
- Oxygen saturation 94% on room air
1200:
Client presents to ED with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States they went to a music concert recently "and probably picked up some kind of virus."
Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 109/min, S152 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea, rate of 28/min. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts."
Client reports they have not had a pneumococcal vaccine and does not get annual influenza vaccinations. States, "I just hate needles."
1215:
70 years of age
No significant medical history other than primary concern Well nourished
Home Medications:
Daily multi-vitamin Vitamin D
Social History
Lives alone, partner died 5 years ago
1230:
Chest x-ray:
Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
A nurse in an emergency department (ED) is admitting a client.
Select 4 findings in the client's medical record that place them at risk for pneumonia.
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.
Explanation
Palpate the preauricular nodes (1st):
The preauricular lymph nodes are located in front of the ears, near the temple. The nurse starts at the head and neck to assess the regional nodes. Palpation of the preauricular nodes is often performed first because they are closest to the head and may be involved in infections affecting the eyes, ears, or sinuses.
Palpate the submandibular nodes (2nd):
The submandibular nodes are located beneath the jaw and are often involved in respiratory or oral infections. They are assessed after the preauricular nodes, as they are still part of the head and neck region, just below the chin.
Palpate the supraclavicular nodes (5th):
These nodes are located above the clavicle and are often associated with more serious conditions, such as cancer. Assessing them early in the examination can help identify any potential red flags.
Palpate the axillary nodes (3rd):
The axillary lymph nodes are located in the armpits and are important for breast tissue, upper limb, and chest infections. These are assessed after the head and neck nodes because they are part of the upper body region and located further down, near the chest.
Palpate the popliteal nodes (4th):
The popliteal nodes are located behind the knees. These nodes are assessed next, as part of the lower extremity examination. Palpating these nodes after the axillary nodes ensures a thorough systematic approach from upper to lower body.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
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