ATI Physical Assessment Of An Adult Posttest

Identifies a minty scent Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, ask the patient to identify a nonirritating aroma, such as mint or coffee.

Rebound tenderness This procedure elicits rebound tenderness - an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to the umbilicus) is a sign of acute appendicitis.

Right lower quadrant Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

Has body mass index within normal limits BMI is a measurement of an adult's body fat based on height and weight. Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a normal amount of body fat. A patient with a BMI below 18.5 is considered underweight; a patient with a BMI of 25 or above is considered overweight; and one with a BMI of 30 or above is considered obese.

Balance The most common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of you, with her feet together, toes pointed forward, and her hands at her sides. While you extend your hands so that one is on either side of the patient, ask her to close her eyes. Watch to see how well she can maintain balance in that position. A minimum of swaying is normal, but if the patient sways more than a couple of inches, stop the test and document that the patient demonstrated difficulty maintaining balance on Romberg testing.

Dorsalis pedis In the lower extremities, the most common pulse tested is the dorsalis pedis pulse, found on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.

Insert the earpieces at an angle toward your nose Angling the earpieces toward your nose helps ensure that sounds are effectively transmitted to your eardrums.

Kyphosis Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older patients who have had vertebral fractures.

crackles Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration.

Inspection Inspection is the process of observation. You will first inspect the body systematically, observing for normal as well as abnormal physical signs. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation. Abdominal assessment is an exception, since any manipulation of or pressure on the abdomen may stimulate peristalsis, the waves of contraction that propel contents through the gastrointestinal tract, and thus alter the patient's bowel sounds. So, when assessing the abdomen, inspection is still first, but auscultation comes before percussion and palpation.

To develop a plan of care Remember the nursing process: assessment, diagnosis, planning, implementation, evaluation. Assessment is the first part of the process. It generates the database from which you will make nursing decisions. Your objective in interacting with patients is to identify their needs and concerns and help find solutions. That is the nursing process in action - and your map is the nursing care plan you establish for each patient. Analyzing and synthesizing data will provide the basis for each nursing diagnosis and for the selection of nursing interventions to manage actual or potential health problems.

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is a normal and expected finding when you are preparing to auscultate an apical pulse.